Page 41 - Gosselin Funeral Home

STATE OF: COUNTY OF:
Stock Transfer Requirements
1. Affidavit of Domicile
2. Stock Power Forms
3. Surrogate Papers
4. Copy of Death Certificate
AFFIDAVIT OF DOMICILE
_________________________________________________,being duly sworn, deposed and says: I reside at____________________________________________________________________(street) City/town of:_______________________________________________________________________ County of:_________________________________, State of:_______________________________ and 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: ____________________________________________________________________________(street) City/town of:_______________________________________________________________________ County of:_________________________________, State of:_______________________________ He/She resided in the State of_____________________________________________________for ____________ years prior to death, and was not resident of _____________________________ _____________________ (State of Incorporation of the Stock) or any 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 of the following described securities owned by said decedent at the time of death.
____________________________ shares ______________________________________ ____________________________ shares ______________________________________ ____________________________ shares ______________________________________ ____________________________ shares ______________________________________ ____________________________ shares ______________________________________
That the said securites were physically located in the city of
________________, state of ___________________________ at the date of death of the decedent Sworn to or affirmed before me this ________________________________ day of __________________________________________________, 20______
My commission expires _________________________________________________
Affix Seal
X____________________________________ Signature of Deponent
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