Free affidavit of domicile 26
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Overnight mail:

Pax World Funds
PO Box 9824
Providence RI 02940-8024

Pax World Funds
4400 Computer Drive
Westborough MA 01581-1722
Telephone: 1(800) 372-7827

AFFIDAVIT OF DOMICILE
Account Number
, being duly sworn, deposes and says: That
(Name of Executor/Administrator/Personal Representative/Survivor/Atty)

resides at

(he/she)
, City of

County of

, State of

and is

of the estate of
(Executor/Administrator/Personal Representative/Survivor/Atty)
day of

who died on the

deceased,

, 20

.

That the decedent died a legal resident of the State of
a resident of this state for a period of

and was

years immediately preceding

death.
(his/her)

That the decedent executed no will or other instrument within two years prior to death in which he/she states that
(he/she)

was not a resident of any state other than the State of

.

(Signature of Deponent, and capacity in which affidavit is signed)

State
County
Sworn to me before a Notary Public

this

Day of

, Year

.

(Si