Fillable Printable Sample Affidavit of Domicile
Fillable Printable Sample Affidavit of Domicile
Sample Affidavit of Domicile
Code 0088 Rev. 01/15
AFFIDAVIT OF DOMICILE
M ER RILL LYN CH
ACCOUNT NUMBER ___________________________________
I, _________________________________________________________________ being duly sworn, depose and state as follows:
Affiant (Your Name. If a Corpor ate Fiduc iary , Show Name & Title of Individual Sig ning, & Name and Addre s s of C orpor ation)
I reside at _________________________________________ (street address), City of___________________________________,
County of _______________________________________________, State of ______________________________, and am
Please check one:
□ executor □ personal representative □ administrator □ survivor of joint tenancy □ heir at law
of __________________________________________________ (deceased) who died on ____day of ________, 20________.
(day) (Month) (Year)
At the time of death, the decedent’s residence and do micile (legal residence) was in the City of __________________________,
County of ____________________________________________, and State of ______________________________________;
and had been the same for the preceding ___________________ years. The decedent’s last Federal income tax return showed
the decedent’s residence and domicile was in the City of __________________________________________________________,
Count y o f ____________________________________________, and State of ________________________________________.
The decedent last voted i n t he City of _ _ _______________________, and State of _____________________________________.
The decedent was not at any time during the year preceding the date of death a resident of or domiciled in any state within the
United State s of America ot her than the state o f do micile sh own above. T he decedent executed no will or instr ument withi n three
years prior to death in which the decedent stated he /she was a resident of any other Sta te.
This affidavit is made for the purpose of securing the transfer or delivery of property o wned by the decedent at the time of his or
her death to a purchaser or persons le gally entitled thereto under the la ws of the decedent’s d o micile.
__________________________________________________ ____________
Signature of Affiant Date
Note: CALIFORNIA-LICEN SE D NO TARI ES
Notarization is
Required
State
of______________________________________
County of ____________________________________
Subscribed and sworn to (or affirmed) before me this
day
of
,
20______,
(day) (month) (year)
by , proved to me on the basis of satisfactory
(Name of Affiant)
evidence to be the person(s) who appeared before me.
_____________________________________________________ ______________________
Signature of Notary Public (Affix Seal or Stamp)
_____________________________________________________
Print Name of Notary Public
Personally Known ______________________________________ OR Produced Identification ________________________________
Type of Identification Produced______________________________________________
A notar y public or other officer completing this certificate verifies
only the identity of the individual who signed the documents to
which this certi ficat e is attached , and not th e truthfuln es s , accuracy,
or validity of that document.
