AFFIDAVIT OF DOMICILE
STATE OF _______________________________)
) SS ______________________
COUNTY OF _____________________________)
___________________________________________ , being duly sworn, deposes and
says that (he/she/they) resides at ___________________________________________
State of ____________________________ , and is Executor
)
Administrator of the Estate of)
Survivor with joint tenancy ) _____
____________________________ , Deceased who died at ___________________ on the
____________________ day of ____________ , 20 ___ , that at the time of his/her death
the domicile (legal residence) of said decedent was at ____________________________ ,
County of ______________, State of __________________ , that decedent resided at such
address for __________ years, such residence having commenced on ___________ ,
____ , that decedent last voted in the year _____ at _________________ County of
______________ , State of ___________________ , that decedent's principal place of
business at the time of his/her death was at ______________ , County of ___________ ,
State of __________________ , that decedent's most recent Federal Income Tax Return
showed his legal residence as _______________________ , County of ____________ ,
State of _____________________ ; that within three years prior to death decedent was not
a resident of another state ("if decedent resided in another state within three years prior to
death, set forth the name of the state and facts as to change of residence and establishment
of final domicile) ;