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1, __________________ (State Your Role), residing at ________________________, being first duly sworn, state as follows:

I am the _____________________ (Your Role) of the Estate of ___________________ (“Decedent”) who died on ____________ (“Date of Death”).

At the time of death, the Decedent's domicile was _____________________________, and the Decedent had resided in the State of ___________________ and was not a resident of any other state of the United States at the time of death.

The Decedent did not claim any state of domicile other than the State of _____________

on any instrument or Will executed within the two years prior to death.

Certificate(s) representing ___________________ were physically located in ________, at the time of the Decedent's death.

__________________

Maker of Affidavit

Subscribed and sworn to before me this __ day of ________, 20__.

_____________

Notary Public

My Commission Expires on: ______________

Review List

This review list is provided to inform you about the document in question and assist you in its preparation. An Affidavit of Domicile is a good document to have and create for the purpose of collecting assets as well as for filing state and federal estate tax returns, should they be due. This document is especially important to have in place if Decedent lived in different states, especially if one was a higher taxed state for Estate tax purposes.

1. The Affidavit of Domicile should be signed in the presence of a notary public.

2. Make a copy of the Affidavit to keep with your records pertaining to the estate.

3. Provide the original, along with other necessary documents to the corporation or broker who will be handling the transfer of what you are transferring that requires a copy of this Affidavit. Other necessary documents to include may be a "Stock Power" and "Letters of Appointment" statement or certificate.