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AFFIDAVIT OF DOMICILE
(One affidavit required at time of transfer for the stock/bond of each company)

State of
County of

The undersigned John Doe

, residing

at Home address

being duly

sworn, deposes, and says: that I am Executor/trix, Administrator/trix, Personal
Representative, Trustee, Surviving Joint Tenant
John Doe
of (name of deceased)
Jane Doe
who died on (date of death) 1/1/10
that at the time of death the domicile
(legal residence) of the decedent was at:
Home address at time of death
and that (s)he resided in the State of home state at time of death for XX years prior to
death and was not a resident of any (other) state within the United States of America at
the time of death.
This affidavit is made for the purpose of having securities, bonds, funds and monies
transferred.

Signature
Sworn to and subscribed before me this
day of
, 2____
(Signature of Notary Public)

My commission expires