Sample Affidavit of Domicile
Code 0088 Rev. 01/15
AFFIDAVIT OF DOMICILE
M ER RILL LYN CH
ACCOUNT NUMBER ___________________________________
I, _________________________________________________________________ being duly sworn, depose and state as follows:
Affiant (Your Name. If a Corpor ate Fiduc iary , Show Name & Title of Individual Sig ning, & Name and Addre s s of C orpor ation)
I reside at _________________________________________ (street address), City of___________________________________,
County of _______________________________________________, State of ______________________________, and am
Please check one:
□ executor □ personal representative □ administrator □ survivor of joint tenancy □ heir at law
of __________________________________________________ (deceased) who died on ____day of ________, 20________.
(day) (Month) (Year)
At the time of death, the decedent’s residence and do micile (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 __________________________________________________________,
Count y o f ____________________________________________, and State of ________________________________________.
The decedent last voted i n t he 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 State s of America ot her than the state o f do micile sh own above. T he decedent executed no will or instr ument withi n three
years prior to death in which the decedent stated he /she was a resident of any other Sta te.
This affidavit is made for the purpose of securing the transfer or delivery of property o wned by the decedent at the time of his or
her death to a purchaser or persons le gally entitled thereto under the la ws of the decedent’s d o micile.
Signature of Affiant Date
Note: CALIFORNIA-LICEN SE D NO TARI ES
County of ____________________________________
Subscribed and sworn to (or affirmed) before me this
(day) (month) (year)
by , proved to me on the basis of satisfactory
(Name of Affiant)
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______________________________________________
A notar y public or other officer completing this certificate verifies
only the identity of the individual who signed the documents to
which this certi ficat e is attached , and not th e truthfuln es s , accuracy,
or validity of that document.
Sample Affidavit of Domicile PDF
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