) ) SS ) STATE OF COUNTY OF AFFIDAVIT OF DOMICILE , being duly sworn, deposes and says That he/she resides at State of and is the of Deceased; who died at (i.e.son/daughter/Petitioner/Fiduciary) day of on the , ; At the time of his/her death the domicile (legal residence) of said decedent was at State of County of ; That the decedent resided at such address for that the decedent last voted in the year at ; State of years, such residence having commenced on County of That decedent's principal place of business at the time of his death was at County of State of ; That the Decedent's most recent Federal income tax return showed his legal residence as County of State of ; That within three years prior to death, decedent was not a resident of another State. If decedent resided in another State within three years prior to death, set forth the name of the state and the facts as to change of residence and establishment of final domicile: Sworn to (or affirmed) before me, this day of , 20 (Give official capacity of official administering oath) My commission expires: (Notary Seal) pcpfc - c.g.f.