Affidavit of Domicile Form - American Stock Transfer

Affidavit of Domicile
Page 1 of 2: Form
Instructions are located on page 2.
Please print clearly.
1
Name of Stock to Be
Transferred:
2
AST Account Number:
This form must be completed by the executor, administrator, personal representative, or survivor.
3
Full Name of Person
Completing this Form:
I am the (check one):
Executor
Administrator
Personal Representative
Survivor
4
Legal Address of
Person Listed Above:
5
Full Name of
Decedent:
6
Date of Death of
Decedent:
7
Legal Residence of
Decedent:
City
of :
State
of:
County
of:
8
I, being duly sworn, depose and say that I am the executor, administrator, personal representative, or survivor (as
checked above) of the Estate of the decedent, whose name, date of death and legal residence are listed above.
Signature of person
completing this form:
X
This affidavit confirms that American Stock Transfer & Trust Company, LLC (AST) is the transfer agent that has
permission to transfer or deliver securities registered in the name of, or owned by, said decedent at the time of his/her death.
Official Notary Public Certification and Seal
9
Sworn before me on this date:
Day of
, 20
AFFIX NOTARY PUBLIC SEAL BELOW
Signature of
Notary Public:
X
Expiration of
Commission:
Page 1/2
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Affidavit of Domicile Form - American Stock Transfer PDF

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