Fillable Printable Affidavit of Domicile Form - American Stock Transfer
Fillable Printable Affidavit of Domicile Form - American Stock Transfer
Affidavit of Domicile Form - American Stock Transfer
Affidavit of Domicile
Page 1 of 2: Form
Instructions are located on page 2.
Please print clearly.
1
Name of Stock to Be
Transferred:
2
AST Account Number:
Enter the AST 10-digit numerical account number
printed on all account mailings.
This form must be completed by the executor, administrator, personal representative, or survivor.
3
Full Name of Person
Completing this Form:
I am the (check one):
Executor
Administrator
Personal Representative
Survivor
4
Legal Address of
Person Listed Above:
5
Full Name of
Decedent:
6
Date of Death of
Decedent:
7
Legal Residence of
Decedent:
City
of :
State
of:
County
of:
8
I, being duly sworn, depose and say that I am the executor, administrator, personal representative, or survivor (as
checked above) of the Estate of the decedent, whose name, date of death and legal residence are listed above.
Signature of person
completing this form:
X
This affidavit confirms that American Stock Transfer & Trust Company, LLC (AST) is the transfer agent that has
permission to transfer or deliver securities registered in the name of, or owned by, said decedent at the time of his/her death.
Official Notary Public Certification and Seal
9
Sworn before me on this date:
Day of
, 20
AFFIX NOTARY PUBLIC SEAL BELOW
Signature of
Notary Public:
X
Expiration of
Commission:
Affidavit of Domicile
Page 2 of 2: Instructions
Please read carefully.
Please enter all of the information in the presence of a notary.
1
Full name of the stock to be transferred
2
AST 10-digit numerical account number printed on all account mailings
3
Full name of the executor, administrator, personal representative, or survivor and check the box next to
the capacity
4
Legal address of the executor, administrator, personal representative, or survivor
5
Full name of the decedent
6
Date of death for the decedent
7
Legal residence of the decedent
8
Executor, administrator, personal representative, or survivor must sign his/her name
9
Official notary public to complete certification and affix seal
Once you have completed this form, please send it to AST along with any other appropriate documentation to
the address below.
American Stock Transfer & Trust Company, LLC
Attention: Transfer Department
6201 15th Avenue
Brooklyn, NY 11219
IMPORTANT! Steps 1-8 are to be completed by the executor, administrator, personal
representative, or survivor in the presence of a notary. Step 9 should be completed by an
official notary public.
