Affidavit Of Domicile Form printable pdf download

Affidavit Of Domicile Form

Affidavit of Domicile

STATE OF

)

) SS:

COUNTY OF

)

_________________________________, being duly sworn, deposes and says: I reside at

_____________________________________, Street, City of _____________________, County

of ___________________________, State of ______________________, and am Executor /

Administrator / survivor of ____________________________, deceased, who died on the

________ day of _________________, 20____. At the time of death the legal residence of said

decedent was ___________________________________ Street, City of___________________

__________________________, County of ________________________, State of___________

__________________. He/She resided in the State of ______________________ for

______years prior to death, and was not a resident of ____________________________(state

of Incorporation of the Stock) or any State (other than that of his/her Domicile) within the

United States of America, at the time of death.

This affidavit is made for the purpose of securing the transfer of the following described

securities owned by said decedent at the time of death.

______________________________ Shares____________________________________

That the said securities were physically located in the City of _____________________, State of

__________________ at the date of the death of decedent.

Sworn to or affirmed

Before me this _________________

Day of _________________ 20____

My Commission expires_____________

(Affix Seal)

X______________________________

(Signature of Deponent)

Affidavit Of Domicile Form