Fillable Printable Affidavit of Domicile Form Sample

Affidavit of Domicile Form Sample

AFFIDAVIT OF DOMICILE FORM

I. ACCOUNT INFORMATION

ACCOUNT TITLE: ACCOUNT NUMBER:

—

II. DECEDENT’S INF ORMATION

I, being duly sworn, state that: I reside at

(Name o f Executor/Administrator/ Survivor)

, City of County of S tate of ,

(Street Address)

a nd I am Executor/Administrator/Survivor of , d eceased,

(Name of Deceased)

who died on the day of , 2 0 _ . At the time of death the legal residence of s aid decedent was

, City of County of S tate of ,

(Street Address)

He/She resided in the S tate of for years prior to death, and was not a resident of any other state within

the United S t ate of Ameri ca, at the time of death. This af f idavit is for the purpose of s ecuring the transf er or delivery of

the s ecurities regis tered in the name of or owned by the decedent at the time of his or her death.

III. SIGNATURE

AUTHORIZED SIGNATURE: DATE:

SUBSCRIBED AND SWORN TO BEFORE ME THIS: DAY OF , 20 .

NOTARY PUBLIC:

INTRODUCING BROKER-DEALER NAME: