Fill and Sign the Domicile Document Form

AFFIDAVIT OF DOMICILE COMES NOW, _________________________________________________, resident of _________________, County of _______________, State of ______________________ and who makes this his/her Statement and Affidavit upon oath and affirmation of belief and personal knowledge that the following matters, facts and things set forth are true and correct to the best of his/her knowledge: 1. That Affiant ______________________________, currently resides at ______________ ___________________, State of ________________________; 2. That Affiant is the administrator (executor or surviving tenant) of the Estate of: _____________________________________________ (Full name of Decedent) who died at _________________________________________________, City of _______________, State of _________________ on _____________ , ________ ; 3. That Decedent’s domicile (legal residence) at the time of his/her death was at _________ ________________________, County of ________________, State of ______________ 4. That Decedent resided at such address for _______ years, such residence having commenced on the _________________________, _________; 5. That Decedent last voted in a public election in the year of __________ at ____________________, County of ________________, State of _________________; 6. That Decedent’s principal place of business at the time of his/her death was at ________________________, County of ______________, State of ________________; 7. That Decedent’s most recent Federal Income Tax Return showed his/her legal residence as __________________________________, County of _____________________, State of _____________________; 8. That during the three year period prior to death Decedent (was/was not) a resident of another State (if Decedent resided in another State within three (3) years prior to death, set forth the name of the State and facts to support change of residence and establishment of final domicile); 9. That all debts, taxes and claims against the estate have been paid or provided for; - 1 - 10. That this Affidavit is made for the purpose of securing the transfer or delivery of property owned by the decedent at the time of (his/her) death to the person or persons legally entitled thereto under the laws of decedent’s domicile and any apparent inequality in distribution has been satisfied or provided for out of other assets in the estate. WITNESS my signature, this _____day of ________, ______. ________________________________ Signature of Affiant STATE OF ____________________ COUNTY OF __________________ On __________________, before me, ______________________ (name/title of officer), personally appeared ________________________, personally know to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument and acknowledged to me that he executed the same in his authorized capacity, and that by his signature on the instrument the person, or the entity upon behalf of which the person acted, executed the instrument. Witness my hand and official seal. Signature ________________________ - 2 -