Free affidavit of domicile 01
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STATE OF________________________)
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
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