Affidavit Of Domicile Form printable pdf download

Broadridge Corporate Issuer Solutions

PO Box 1342

Brentwood, NY 11717

Affidavit of Domicile

State of: _________________________________

County of: ____________________________________________

Name of Stock: (Issuer): _________________________________

Name(s) on the Account: __________________________ Name(s) on the Account: _____________________________

Deceased Holder’s Tax Identification Number (TIN) or Social Security Number __________________________________

I / We, the undersigned _______________________________ being duly sworn, depose and say that (I/we) reside at

____________________________________

the

state

__________________________

and/am

are

____________________________(describe your status such as Executive Administrator, Survivor in Joint Tenancy, if a

corporate fiduciary show title of affiant and name of corporation) of ___________________________________________

who died on the _________________ day of _________________________, 20 _______ that at the time of death the

domicile (legal residency) of said decedent was at _____________________________________________________

County

of___________________________________,

State

of_________________________________

that

the

decedent reside at such address for _________ years prior to death and was not a resident of any (other ) State within

the United States of America at the time of death.

That any and all debts, taxes, legacies and claims against the estate have been paid or provided for; that this affidavit is

made for the purpose of securing the transfer or delivery of property owned by the decedent at the time of his/her death to

a purchaser or the person or persons legally entitle thereto under the laws of the decedent’s domicile; and that any

apparent inequality in distribution has been satisfied or provided for out of other assets in the estate.

Place Notary Seal Here

Signature(s): (Executor, Administrator, or Survivor)

______________________________________________

Sworn to before me, a notary public this

______ Day of ____________________, 20___________

Notary Public Commission Expires: ________________

Affidavit of Domicile. Version 1.2.1.31.2013

Affidavit Of Domicile Form