Fillable AFFIDAVIT OF DOMICILE COUNTY OF ) , being (Shareowner Online)

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AFFIDAVIT OF DOMICILE COUNTY OF ) , being (Shareowner Online)

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AFFIDAVIT OF DOMICILE
STATE OF )
)SS:
COUNTY OF )
, being duly sworn deposes and says that he/she
resides at , State
of and is executor/administrator of the estate of
deceased, who died on the day of
20 ; at the time of his/her death the domicile (legal residence) of said decedent was
(address),
County of , State of for years prior to
death, and was not a resident of any other State (other than that of his/her domicile) within the United States of America, at
the time of death.
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/her death.
(EXECUTOR/ADMINISTRATOR/SURVIVOR/HEIR)
Subscribed and sworn to before me
this day of , 20
(NOTARY PUBLIC)
My commission expires
AoD Dom V2
11/18
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AFFIDAVIT OF DOMICILE COUNTY OF ) , being (Shareowner Online)

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Completed 23 September 2021

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