AFFIDAVIT OF DOMICILE
I, being duly sworn, depose and state as follows:
I reside at (street address), City of , County of , State of , and am
Please check one:
survivor of joint tenancy
heir at law
of (deceased) who died on day of , 20.
At the time of death, the decedent’s residence and domicile (legal residence) was in the City of , County of , and State of ;
and had been the same for the preceding years. The decedent’s last Federal income tax return showed the decedent’s residence and domicile was in the City of , County of , and State of . The decedent last voted in the City of , and State of .
The decedent was not at any time during the year preceding the date of death a resident of or domiciled in any state within the United States of America other than the state of domicile shown above. The decedent executed no will or instrument within three years prior to death in which the decedent stated he /she was a resident of any other State.
This affidavit is made for the purpose of securing the transfer or delivery of property owned by the decedent at the time of his or her death to a purchaser or persons legally entitled thereto under the laws of the decedent’s domicile.
Signature of Affiant Date
Notarization is Required
State of County of
Subscribed and sworn to (or affirmed) before me this day of , 20, by , proved to me on the basis of satisfactory evidence to be the person(s) who appeared before me.
Signature of Notary Public (Affix Seal or Stamp)
Print Name of Notary Public
Personally Known OR Produced Identification
Type of Identification Produced
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