Affiant Identification and Capacity
Affiant Full Name: [[Affiant Full Name]]
Affiant Relationship to Decedent: [[Affiant Relationship to Decedent]]
The Affiant is the [[Affiant Relationship to Decedent]] of the Decedent and is acting in the capacity of executor, administrator, or other authorized representative of the estate of the Decedent. If appointed by a court, the Affiant's authority is evidenced by Letters Testamentary or Letters of Administration issued by the court having jurisdiction over the estate.
Affiant Address: ________________________________________________
Affiant City, State, ZIP: ________________________________________________
Affiant Telephone: ________________________________________________
Affiant Email: ________________________________________________
Decedent Identification
Decedent Full Name: [[Decedent Full Name]]
Date of Death: [[Date of Death]]
Place of Death (if known): ________________________________________________
Last Known Address of Decedent: ________________________________________________
Estate or Probate File Number (if assigned): ________________________________________________
Court Having Jurisdiction (if applicable): ________________________________________________
The Affiant attaches or will provide upon request a certified copy of the Decedent's death certificate as evidence of the date of death.
Domicile at Time of Death
State of Domicile at Death: [[State of Domicile]]
County of Domicile: [[County of Domicile]]
City or Town of Domicile: ________________________________________________
Domicile is the place where the Decedent had a fixed and permanent home with the intention of returning whenever absent. It is the place to which the Decedent was legally subject and which the Decedent regarded as home. Domicile is not the same as mere residence or temporary presence.
The Affiant states under oath that at the time of the Decedent's death, the Decedent's legal domicile was the State of [[State of Domicile]], County of [[County of Domicile]]. The Decedent was not a resident or domiciliary of any other state or jurisdiction for probate or tax purposes.
- The Decedent maintained a permanent home at the address in the State of Domicile for a substantial period prior to death.
- The Decedent's personal effects, family connections, and primary business or professional activities were centered in the State of Domicile.
- The Decedent filed state and federal tax returns listing the domicile address or intended to do so for the year of death.
- The Decedent held a driver's license, voter registration, or other official documents reflecting the domicile address.
- The Decedent had not abandoned or changed domicile to another jurisdiction prior to the date of death.
Purpose of This Affidavit
This Affidavit is executed for the purpose of establishing the Decedent's state of domicile at death to facilitate the transfer, release, or re-registration of securities, brokerage accounts, mutual fund shares, and other intangible personal property without the necessity of ancillary probate administration in any jurisdiction other than the state of domicile.
The Affiant requests that any transfer agent, broker, custodian, bank, or other financial institution or entity holding assets of the Decedent rely upon this Affidavit and the attached or referenced documentation to transfer or release the assets to the proper successor or distributee.
Assets and Securities to Be Transferred
Description of Securities / Assets: [[Securities/Assets Description]]
Approximate Value or Number of Shares (if known): ________________________________________________
Name of Broker, Transfer Agent, or Custodian (if known): ________________________________________________
Account or Certificate Numbers (if known): ________________________________________________
Transfer Destination / Name of Recipient or Estate Account: [[Transfer Destination]]
The assets described above, or additional assets of the same general description that may later be identified, are the subject of this Affidavit. The Affiant affirms that the assets are part of the Decedent's estate and that the transfer is being made in accordance with the Decedent's will, the laws of intestate succession of the state of domicile, or other lawful authority.
Supporting Documentation
The following documents are attached or available upon request:
- Certified copy of the Decedent's death certificate.
- Copy of the Decedent's will (if probated) or summary of intestate heirs.
- Letters Testamentary or Letters of Administration (if issued).
- Tax waiver or release from the state of domicile tax authority (if required).
- Stock powers or other transfer documents executed by the Affiant in the proper capacity.
- Any other documentation reasonably requested by the transfer agent or institution.
Oath and Affirmation
The Affiant solemnly swears under penalty of perjury under the laws of the State of [[State of Domicile]] and the United States of America that the foregoing statements are true and correct to the best of the Affiant's knowledge, information, and belief. The Affiant understands that any false statement made herein may subject the Affiant to criminal penalties for perjury.
The Affiant further affirms that this Affidavit is made for the purpose of inducing reliance by transfer agents, brokers, and other institutions and that the Affiant has not omitted any material fact that would affect the statements made.
Signature of Affiant
Signature of Affiant: ______________________________________________
Printed Name: [[Affiant Full Name]]
Relationship to Decedent: [[Affiant Relationship to Decedent]]
Date Signed: ______________________________________________
Notary Jurat
State of ____________________
County of ____________________
On this ___ day of ______________, 20__, before me, the undersigned notary public, personally appeared [[Affiant Full Name]], proved to me through satisfactory evidence of identification, which was/were _______________________________, to be the person whose name is signed on the preceding or attached document, and acknowledged to me that they signed it voluntarily for its stated purpose.
Notary Public Signature: ______________________________________________
Printed Name of Notary: ______________________________________________
My Commission Expires: ______________________________________________
(Notary Seal)
Acknowledgment by Transfer Agent or Institution (Optional)
The undersigned transfer agent, broker, or custodian acknowledges receipt of this Affidavit and agrees to process the requested transfer or release of the securities or assets described herein upon compliance with its standard requirements and receipt of any additional documentation it may reasonably request.
Institution Name: ______________________________________________
Authorized Officer Signature: ______________________________________________
Printed Name and Title: ______________________________________________
Date: ______________________________________________
Additional Provisions
- This Affidavit may be relied upon by any successor transfer agent, broker, or custodian without further verification of the Affiant's authority beyond the documentation presented.
- The Affiant agrees to indemnify and hold harmless any institution that relies in good faith on this Affidavit from any claims arising from a later determination that the statements herein were inaccurate, to the extent permitted by law.
- If the domicile of the Decedent is later determined to be a different jurisdiction, the Affiant will promptly notify all parties who received this Affidavit and will take all steps necessary to correct any transfers made in reliance hereon.
- This Affidavit is intended to satisfy the standard requirements of the Depository Trust Company (DTC), major brokerage firms, and transfer agents for non-probate transfers of securities.
Summary of Key Facts Table
| Item | Value |
|-----------------------------|--------------------------------------------|
| Affiant Full Name | [[Affiant Full Name]] |
| Affiant Relationship | [[Affiant Relationship to Decedent]] |
| Decedent Full Name | [[Decedent Full Name]] |
| Date of Death | [[Date of Death]] |
| State of Domicile | [[State of Domicile]] |
| County of Domicile | [[County of Domicile]] |
| Securities/Assets Desc | [[Securities/Assets Description]] |
| Transfer Destination | [[Transfer Destination]] |
Disclaimer
This Affidavit of Domicile is a sample template designed to meet standard transfer-agent and brokerage requirements for establishing a decedent's state of legal domicile for purposes of transferring securities and other intangible assets without ancillary probate. It incorporates the required elements of affiant identity and relationship, decedent identification, date of death, domicile statement distinguishing domicile from mere residence, description of assets, purpose of the affidavit, and a notary jurat with signature and seal block.
Laws governing domicile, probate, and securities transfers vary by state. The state of domicile at death generally controls the applicable probate law and may affect tax obligations. Transfer agents and institutions may impose additional requirements, including tax releases, indemnity agreements, or court orders. The Affiant and any recipient of this document should verify current requirements with the specific institution and consult qualified probate or estate counsel in the relevant jurisdiction. This document is not legal advice and does not guarantee acceptance by any particular institution. Information is current as of June 2026.
