Free affidavit of domicile 18
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(One affidavit required at time of transfer for the stock of each company)
STATE OF__________________________________
COUNTY OF____________________________________
(Name of Company)

_________________________________________________________________ residing at
_________________________________________________________________ being
duly sworn, disposes and says
[ ] Executor
[ ] Administrator
I am _________________________________________ [ ] Survivor in Joint Tenancy

of (name of deceased) _______________________________________________who
died on___________________________________and that he/she resided in the State
of__________________________ for _______ years prior to his/her death, and was not
a resident of any (other) State within the United States of America at the time of death.

(Legal Signature)

Sworn to before me a Notary Public