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Affidavit of Domicile

AD

Instructions: Use this form to complete legal transfers of securities upon the death of an owner. This form verifies residency of the deceased at the time of death
and must be notarized.
Please mail the completed form to LPL Financial, Attn: Trade Direct, P.O. Box 509049 San Diego, CA 92150-9049; original signature is required.

Account Information
LPL Account Number

Account Registration

Social Security / Tax ID Number
State

County

The account named above is held in the following:

Security Name and Securities Description
This affidavit is made for the purpose of transferring shares of the security named below as requested. If the transfer constitutes an apparently uneven
distribution, the matter has been equalized by the distribution of other securities or in some other manner.
Full Name of Security

At the time of death, the securities described above were physically located in:
City

County

State

Signature and Notary
The undersigned, duly sworn, depo