Affidavit of Domicile Template

This Affidavit of Domicile (the “Affidavit”) is made on [Date] by:

Affiant: [Full Name], address: [Address], phone/email: [Contact].
Relationship/Authority: ☐ Executor/Personal Representative ☐ Surviving Spouse ☐ Heir ☐ Other: [Explain]

Decedent: [Full Legal Name]
Date of Death: [Date]
Place of Death (City/State): [City/State]

1. Purpose

1.1 I am making this Affidavit to confirm the Decedent’s legal domicile for estate administration and/or transfer of assets.

2. Domicile Information

2.1 Domicile Address: [Street, City, State, ZIP/Country].
2.2 Time at This Address: The Decedent lived at this address from approximately [Month/Year] until [Date of death].
2.3 Permanent Home Statement: To the best of my knowledge, the Decedent considered this address to be their permanent home and intended to remain domiciled there.

3. Other Residences (If Any)

3.1 The Decedent had other residences: ☐ No ☐ Yes (describe):

• Address: [] | Use: ☐ vacation ☐ temporary work ☐ family ☐ other: []

• Time period: [__]

3.2 These other residences did not change the Decedent’s domicile as stated above, to the best of my knowledge.

4. Estate and Identification (Optional)

4.1 Estate/Case (If Any): [Court/County], Case No.: [__].
4.2 Letters/Appointment (If Any): Issued on [Date] (attach copy if available).
4.3 Decedent Tax ID/SSN (Last 4 digits only): [____].
4.4 Asset Holder/Institution (If Applicable): [Bank/Broker/Transfer Agent name].

5. Supporting Documents (Attach as Available)

5.1 ☐ Certified death certificate
5.2 ☐ Letters testamentary/administration (if applicable)
5.3 ☐ Proof of address (utility bill, ID, tax record)
5.4 ☐ Will (if applicable)
5.5 ☐ Other: [List]

6. Statement Under Oath

6.1 I declare under penalty of perjury that the statements in this Affidavit are true and correct to the best of my knowledge.

Signatures

Affiant: [Full Name]
Date: [Date]
Signature: ___________________________

Witnesses (If Required)

Witness Name: [Name]
Date: [Date]
Signature: ___________________________

Notary / Notarization (If Required)

State of [State]
County of [County]

On [Date], before me, [Notary Name], personally appeared [Affiant Full Name], known to me (or satisfactorily proven) to be the person whose name is subscribed to this Affidavit, and acknowledged that they executed it for the purposes stated.

Notary Public Signature: _______________________
My Commission Expires: _______________________
Notary Seal (if applicable): ___________________