Free affidavit of domicile 02Free affidavit of domicile 02
Download the document to the computer for easy use
There are more pages to preview,Read on

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:

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:

Name of
5 Full
Decedent:
of Death of
6 Date
Decedent:

MM/DD/YYYY

Legal Residence

7 of Decedent:

City

State

County

of :

of:

of:

being duly sworn, depose and say that I am the executor, administrator, personal representative, or survivor (as
8 I,checked
above) of the Estate of the registered owner, whose name, date of death and legal residence are listed above.
Signature of person
completing this form:
This affidavit confirms that American Stock Transfer & Trust Company, LLC ("AST") is the transfer agent that has permission
to transfer or deliver securities