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.










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





Notary Public