Fillable Printable Affidavit of Domicile Form - Wells Fargo

Affidavit of Domicile Form - Wells Fargo

AFFIDAVIT OF DOMICILE

STATE OF________________________)

)SS:

COUNTY OF______________________)

_______________________________________________, being duly

sworn deposes and says that he/she resides at

___________________________________________________________,

State of _____________________________ and is executor/administrator of

the estate of ____________________________________ deceased, who

died on the __________ day of______________ 20_______; at the time of

his/her death the domicile (legal residence) of said decedent was

_________________________________________________________,

(address)

County of ________________________________, State of

__________________________ for _______ years prior to death, and was

not a resident of any other State (other than that of his/her domicile) within

the United States of America, at the time of death.

This affidavit is made for the purpose of securing the transfer or delivery of

securities registered in the name of or owned by said decedent at the time of

his/her death.

_____________________________________________

(EXECUTOR/ADMINISTRATOR/SURVIVOR/HEIR)

Subscribed and sworn to before me

this ______ day of ___________, 20______

___________________________________

(NOTARY PUBLIC)

My commission Expires _______________