Free affidavit of domicile 11Free affidavit of domicile 11
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MGE Energy, Inc.
Shareholder Services
Affidavit of Domicile
Follow these instructions to complete the Affidavit of Domicile form:
1.

State where form is being completed.

2.

County where form is being completed.

3.

Social Security Number of person completing form.

4.

Name of person completing form.

5.

Address of person completing form.

6.
7.

Indicate your relationship to deceased shareholder (circle applicable relationship listed or fill in blank
line).
Name of deceased shareholder.

8.

Place of death for shareholder.

9.

Day of death.

10.

Month of death.

11.

Year of death.

12.

Address of deceased shareholder.

13.

County in which deceased shareholder resided.

14.

State in which deceased shareholder resided.

15.

Number of years shareholder resided at such address.

16.

Place of business of shareholder at time of death.

17.

County of place of business.

18.

State of place of business.

19.

Signature of legal representative or survivor completing form.

20.

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