Fillable Printable Affidavit of Domicile Form Sample
Fillable Printable Affidavit of Domicile Form Sample
Affidavit of Domicile Form Sample
AFFIDAVIT OF DOMICILE FORM
I.ACCOUNT INFORMATION
ACCOUNT TITLE: ACCOUNTNUMBER:
—
II.DECEDENT’S INF ORMATION
I, being duly sworn,state that: Iresideat
(Name o fExecutor/Administrator/Survivor)
,Cityof County ofS tate of ,
(StreetAddress)
a nd I amExecutor/Administrator/Survivor of , d eceased,
(NameofDeceased)
who died on the day of , 2 0 _ . At the time of death thelegalresidenceof s aiddecedentwas
,Cityof County ofS tate of ,
(StreetAddress)
He/Sheresided in the S tate of for yearspriorto death,and was not aresidentofany otherstatewithin
the UnitedS t ate ofAmeri ca, atthe time ofdeath. This af f idavit is for thepurposeof s ecuring the transf er ordeliveryof
the s ecuritiesregis tered inthe name of or ownedby thedecedent at the time of his or her death.
III.SIGNATURE
AUTHORIZEDSIGNATURE:DATE:
SUBSCRIBED AND SWORN TO BEFORE ME THIS: DAYOF, 20.
NOTARY PUBLIC:
INTRODUCING BROKER-DEALERNAME:
