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Regular mail:
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