AFFIDAVIT OF DOMICILE FORM
I. ACCOUNT INFORMATION
II. DECEDENT’S INFORMATION
I, being duly sworn, state that: I reside at , City of County of State of , and I am Executor/Administrator/Survivor of , deceased, who died on the day of , 20 . At the time of death the legal residence of said decedent was , City of County of State of , He/She resided in the State of for years prior to death, and was not a resident of any other state within the United State of America, at the time of death. This affidavit is for the purpose of securing the transfer or delivery of the securities registered in the name of or owned by the decedent at the time of his or her death.
AUTHORIZED SIGNATURE: DATE:
SUBSCRIBED AND SWORN TO BEFORE ME THIS: DAY OF , 20.
INTRODUCING BROKER-DEALER NAME:
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