AFFIDAVIT OF DOMICILE
Executor/Administration/Survivor of __________________________________, deceased, who died on the
______ day of __________________, 20____. At the time of the death the legal residence of said decedent was
____________________ street, city of _______________________, county of _____________________, state
of _______________________. He/She resided in the State of _______________________, for _____, years
prior to death, and was not a resident of any other State (other than that of his/her Domicile) within the United
States of America, at the time of death.
This affidavit is made for the purpose of securing the transfer of the following described security owned by said
decedent at the time of death.
_________ shares _____________________________________