State of
County of
I, , residing at , the of the deceased person (the "Decedent"), being duly sworn, testify and state as follows:
The Decedent:
Full legal name:
Date of death:
Last known legal residence:
Domicile certification. I hereby confirm that the Decedent, , was a legal resident of at the time of death.
Purpose. This Affidavit is executed to ensure the transfer of securities and/or accounts owned by the Decedent at the time of death, namely , to the persons legally entitled to do so under the laws of the country where the Decedent was residing.
Legal acknowledgment. I, , solemnly confirm and declare that the information provided in this Affidavit is true and accurate to the best of my knowledge. I understand that any false statements may have legal consequences.
This Affidavit was made on .
____________________________
(Place for signature)
State of
Acting in the county of
Sworn to and subscribed before me on ___________________________.
___________________________________
Place for signature
______________________________________
Notary public's name and seal