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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