AFFIDAVIT OF DOMICILE

Name of Security: _________________________

STATE OF _________________________,

COUNTY/PARISH/CITY OF _________________________, SS:

I, _________________________, residing at _________________________, _________________________, ___ __________, being first duly sworn, state as follows:

I am the _________________________ of the Estate of _________________________ (the "Decedent") who died on __________________.

At the time of death, the Decedent's domicile was _________________________, _________________________, and the Decedent had resided in the State of _________________________ for at least ______ years prior to death, and was not a resident of any other state of the United States at the time of death.

The Decedent had not listed any state of domicile other than the State of _________________________ on any instrument or Will executed within the two years prior to death.

The attached certificate(s) representing the above security were physically located in _________________________, _________________________, at the time of the Decedent's death.

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Subscribed and sworn to before me this ____ day of ________, 19___.

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Notary Public