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