Free affidavit of domicile 29Free affidavit of domicile 29
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Merrill Lynch Account Number

Affidavit of Domicile
Merrill Lynch Account Number

All the fields provided below are required.
I,
Declarant (your name, or if a corporate fiduciary, show name and title of individual signing, and name and address of corporation)

being duly sworn, depose and state as follows:

I reside at:
Address
City

State

Zip Code

I am (please check one):
Executor/Executrix
Personal Representative
Administrator/Administratrix
Survivor of Joint Tenancy
Heir at law
Other (please specify)
of
(Name of Decedent)

(MM)

.

/

/

, who died on

(DD)

(YYYY)

At the time of death, the decedent’s domicile (legal residence) was:
Address
City

State

Zip Code

Number of Years the Decedent Resided at This
Address Prior to Death

If the decedent resided in any other state during the three years prior to his or her death, I have
listed those states below.
State

State

State

This affidavit is made for the purpose of securing the transfer or delivery of proper