Affidavit of Domicile
Account Holder: First Name, Middle Initial
I, ____________________________________________, being duly sworn, state that I reside at: ______________________________________________,
City of ___________________________, County of _________________________, State of ________.
I am the Executor/Survivor of: _____________________________________________, who died on the _______day of ____________________, 20____.
(Name of Deceased)
At the time of death, the legal residence of said decedent was ________________________________________________,
City of __________________________, County of _________________________, State of ________. Decedent resided in the State of ______