Fill and Sign the Proof of Domicile Form

Affidavit of Domicile STATE OF       COUNTY OF       PERSONALLY appeared before me, the undersigned authority in and for said county and state,       , who, having been being first duty sworn by (Name of Affiant) the undersigned Notary Public, deposes and says: 1.       resides at       , (Name of Affiant) (Street Address)       , and is executor (or administrator) of the Estate of (City, County, State, Zip Code)       , deceased, who departed this life on the (Name of Decedent)       . (Date) 2. At the time of the death of the said decedent, his domicile (i.e., legal residence) was       , where decedent had resided for       (Street Address, City, County, State, Zip Code) (Number) years. 3. Decedent was not a resident of any other State (other than that of his domicile) within the United States of America, at the time of the death of decedent. 4. This affidavit is made for the purpose of securing the transfer or delivery of securities registered in the name of or owned by said decedent at the time of his death. (Printed Name of Affiant)       (Signature of Affiant) SWORN to and subscribed before me, this the       day of       , 20       . NOTARY PUBLIC My Commission Expires: Affidavit of Domicile Page 1 of 1