Free affidavit of domicile 19
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For Office Use Only: Acct.#______________________________ Office: _____________ Reg. Rep: ________________ Name for Filing: ________________________________________

1072 S. De Anza Blvd. Suite A-205, San Jose, CA 95129
Tel: 408-996-1118 Toll Free: 888-666-6551 Fax: 408-996-1116 Email: [email protected]
Clearing services provided by Hilltop Securities, Inc. Member: NYSE/FINRA/SIPC

Affidavit of Domicile

Affidavit of Domicile

1. Affidavit of Domicile.
Account #: ____________________
I, _____________________________________, being duly sworn, depose and say as follows:
I reside at, _________________________________________, in the State of ____________________ and
am the



Survivor of the Estate of _____________________________________,

deceased, who died on the _____ day of _______________, 20_____. At the time of death, the domicile of the
decedent was in the State of

at the following address (including city, state and zip
. I further certify that