Docket No. AFFIDAVIT OF DOMICILE Estate of: First Name Middle Name Last Name Commonwealth of Massachusetts The Trial Court Probate and Family Court Division Date of Death: I, First Name M.I. Last Name the relationship of the decedent do hereby state from my personal knowledge that the decedent was domiciled at: (Address) (Apt, Unit, No. etc.) (City/Town) (County) , Massachusetts at the time of death based on the following facts. The decedent, at the time of death, was a record owner of the property; The decedent's spouse continues to reside at the property; Many of the decedent's personal effects are located at the property; The decedent filed his/her last income tax return for the year address. The decedent at the time of his/her death was living at the above address and had lived there since The decedent's residence at: (Address) (Apt, Unit, No. etc.) (City/Town) (State) (year) indicating that his/her residence was at the . (Zip) was of a temporary nature due to: and at no time did the decedent intend to abandon his/her domicile at: (City/Town) (County) , Massachusetts Other: SIGNED UNDER THE PENALTIES OF PERJURY I certify under the penalties of perjury that the foregoing statements are true to the best of my knowledge and belief. Date Signature Print Name (Address) (City/Town) (State) (Apt, Unit, No. etc.) (Zip) Primary Phone #: MPC 485 (3/19/12) AFDOM American LegalNet, Inc. www.FormsWorkFlow.com page 1 of 1