Affidavit of Domicile: Transfer Stock (Free Template)
Direct Answer
An affidavit of domicile is a sworn, notarized statement that confirms the decedent's state of legal residence (domicile) at the moment of death so a transfer agent (Computershare, Equiniti, Broadridge, AST) can release securities, apply the correct state inheritance and estate tax, and reissue the shares in the surviving owner's or beneficiary's name. The full affidavit of domicile template below is attorney-drafted on the industry-accepted form, carries the Medallion Signature Guarantee notice, and is structured to submit with the death certificate, letters testamentary, and Stock Power.
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Transfer agent ready · Medallion
28 U.S.C. Section 1746 framework
The Affidavit of Domicile Template
The model affidavit below is built on the industry-accepted form used by Computershare, Equiniti, Broadridge, and AST. Ten numbered paragraphs cover the affiant's identity and capacity, the decedent's identification, the decedent's domicile state at death, the securities at issue, the affiant's authority to transfer, the state inheritance and estate tax position, no revocation of domicile, indemnification of the transfer agent and DTC/ Cede & Co., and the purpose of submission. The Medallion Signature Guarantee block follows the notary jurat.
STATE OF [STATE] )
) ss.
COUNTY OF [COUNTY] )
AFFIDAVIT OF DOMICILE
(Sworn Statement of Decedent's Legal
Residence for Securities Transfer)
BEFORE ME, the undersigned authority, on this day personally
appeared [Affiant Full Legal Name] (the "Affiant"), who, being
by me first duly sworn upon oath, deposed and stated as follows:
1. AFFIANT QUALIFICATIONS. Affiant's full legal name is
[Affiant Full Legal Name]. Affiant resides at [Affiant
Street Address, City, State, ZIP]. Affiant is over the
age of eighteen (18) years and competent to make this
Affidavit. Affiant has personal knowledge of the facts
stated herein.
2. CAPACITY OF AFFIANT. Affiant executes this Affidavit in
Affiant's capacity as [Executor / Administrator /
Personal Representative / Successor Trustee / Surviving
Joint Tenant / Surviving Tenant by the Entirety /
Transfer-on-Death Beneficiary / Surviving Spouse under a
community-property regime / Other: ________________] of
the decedent identified below.
If Affiant is acting under court-issued Letters: Letters
were issued by [Court Name], Cause No. [____], on
[Date], a certified copy of which is attached hereto as
Exhibit A.
3. DECEDENT IDENTIFICATION. The decedent's full legal name
was [Decedent Full Legal Name] (the "Decedent"). The
Decedent was also known as [Aliases as they appear on
the certificate(s) or in the brokerage account records,
if any]. The Decedent's date of birth was [Date of
Birth]. The Decedent's Social Security number ended in
[Last Four Digits Only]. The Decedent died on [Date of
Death]. A certified copy of the Decedent's death
certificate is attached as Exhibit B.
4. STATE OF DOMICILE AT DEATH. At the time of death the
Decedent was, and for [Number] years preceding death had
continuously been, a legal resident and domiciliary of:
[City], [County], [State of Domicile]
Residence Address: [Street Address, City, State, ZIP]
"Domicile" as used herein has its ordinary legal meaning:
the place where the Decedent maintained the Decedent's
true, fixed, and permanent home, and to which, whenever
absent, the Decedent intended to return. Indicia
supporting the stated domicile include the Decedent's
principal residence address, the address shown on the
Decedent's last filed state income tax return, the
address shown on the Decedent's driver's license or
state identification, the Decedent's voter registration,
and the Decedent's homestead designation, where
applicable.
5. SECURITIES IDENTIFIED. This Affidavit is given in
connection with the transfer, re-registration, or
release of the following securities held in the name of
or for the benefit of the Decedent:
Issuer / Fund Name: [Name]
CUSIP (if known): [9-Character CUSIP]
Class of Security: [Common / Preferred / Bond /
ETF / Mutual Fund / Other]
Certificate Number(s): [If certificated; otherwise
state "Book-Entry / DRS"]
Number of Shares / Units: [Number]
Brokerage / Custodian: [Firm Name]
Account Number (last four): [____]
Vesting on the Books: [Sole / JTWROS / Tenants in
Common / TOD Beneficiary /
Custodial / Trust]
If multiple positions are being transferred under this
Affidavit, list each position on Schedule 1 attached
hereto and incorporated by reference.
6. AUTHORITY TO TRANSFER. Affiant has authority to direct
the transfer of the securities identified in Paragraph 5
by reason of:
[Right of survivorship vested in Affiant under the
JTWROS or Tenancy-by-the-Entirety registration / TOD
beneficiary designation on file with the transfer
agent / Letters Testamentary or Letters of
Administration issued by [Court, Cause No., Date] /
Successor-trustee authority under the [Name of Trust]
dated [Date] / Statutory small-estate transfer under
the controlling state code / Court order entered
[Date] in Cause No. ____ / Other: ____________].
7. STATE INHERITANCE OR ESTATE TAX. To the best of
Affiant's knowledge:
(a) The state identified in Paragraph 4 imposes the
following state-level death tax on the transfer
of the securities identified in Paragraph 5:
[None / Inheritance tax / Estate tax / Both]; and
(b) If a state-level death tax applies, the Affiant
either has filed, will file, or has obtained a
consent to transfer or waiver from the state
taxing authority, a copy of which is attached as
Exhibit C; OR the transfer is exempt from the
state-level death tax under [statute, regulation,
or factual basis]; OR no state-level death tax
applies because the state identified in Paragraph
4 imposes none.
8. NO REVOCATION OF DOMICILE. The Decedent did not, on or
before the date of death, take any action to abandon the
domicile identified in Paragraph 4 or to establish
domicile in any other state. Specifically, the Decedent
did not, before death, change the Decedent's principal
residence, voter registration, driver's license state of
issuance, or state income tax filing residence to any
state other than the state identified in Paragraph 4.
9. INDEMNIFICATION OF TRANSFER AGENT AND CUSTODIAN. Affiant
acknowledges that the transfer agent, the brokerage
custodian, the depository (including The Depository Trust
Company and its nominee Cede & Co., where applicable),
and the issuer of the securities (each, a "Holder") are
acting in reliance on this Affidavit when re-registering,
transferring, or releasing the securities identified in
Paragraph 5. Affiant agrees, on behalf of Affiant and the
Decedent's estate, to indemnify and hold each Holder
harmless from any loss, claim, demand, tax, penalty,
interest, or expense (including reasonable attorneys'
fees) arising out of any false statement in this Affidavit
or any after-discovered claim by a person not identified
herein. This indemnification does not waive any rights of
any Holder under applicable state or federal law and does
not limit the Holder's right to require additional
documentation, including a medallion-signature-guaranteed
stock power, before completing the transfer.
10. PURPOSE. Affiant executes this Affidavit for the purpose
of inducing the transfer agent, brokerage custodian, and
depository identified above to transfer, re-register, or
release the securities identified in Paragraph 5 in
accordance with the authority described in Paragraph 6,
and to fix the state of domicile identified in Paragraph
4 for purposes of any state-level death tax compliance.
FURTHER AFFIANT SAYETH NAUGHT.
Executed on this ____ day of ________________, 20____.
____________________________________
AFFIANT
[Affiant Full Legal Name]
[Affiant Street Address]
[City, State, ZIP]
PENALTY-OF-PERJURY DECLARATION (Federal Alternative).
Pursuant to 28 U.S.C. Section 1746, Affiant declares under
penalty of perjury under the laws of the United States of
America that the foregoing is true and correct.
Executed on _______________ at _______________________.
____________________________________
AFFIANT
JURAT / NOTARY ACKNOWLEDGMENT
STATE OF ______________________ )
) ss.
COUNTY OF _____________________ )
Sworn to and subscribed before me by [Affiant Full Legal Name]
on this ____ day of ________________, 20____, who is personally
known to me OR produced ______________________________ as
identification, and who being duly sworn deposed that the
statements in the foregoing Affidavit are true and correct of
the Affiant's own personal knowledge.
____________________________________
NOTARY PUBLIC, State of __________
Printed Name: ______________________
My Commission Expires: _____________
Notary Seal:
MEDALLION SIGNATURE GUARANTEE (Transfer Agent Requirement).
Most transfer agents and FINRA-member firms additionally require
a Medallion Signature Guarantee on the stock power or letter of
instruction accompanying this Affidavit. The Medallion stamp must
be affixed by a bank, broker-dealer, credit union, or savings
institution participating in an approved Medallion Signature
Guarantee Program (STAMP, SEMP, or MSP). The Notary Public
acknowledgment above does NOT substitute for the Medallion
Signature Guarantee.
EXHIBITS:
Exhibit A: Certified copy of court-issued Letters
Testamentary or Letters of Administration
(omit if Affiant acts as surviving joint
tenant, TOD beneficiary, or successor trustee).
Exhibit B: Certified copy of the Decedent's death
certificate.
Exhibit C: Copy of the state-level inheritance or estate
tax waiver, consent to transfer, or proof of
exemption (if the state of domicile imposes a
state-level death tax on the securities
transfer).
Schedule 1: List of additional securities positions covered
by this Affidavit (if more than one position).
The Medallion Signature Guarantee: STAMP, SEMP, and MSP
Five steps from gathering the certified death certificate and authority documents through the Medallion Signature Guarantee and final submission to the transfer agent. The two failure points to watch are the Medallion (not a notarization, a separate financial-industry guarantee) and the domicile statement (a single state, not a list of residences).
- 1
Gather the certified death certificate and authority documents
Order at least three certified death certificates from the state department of health. Locate the letters testamentary (executor) or letters of administration (administrator), or, for joint accounts with right of survivorship, the account agreement showing survivorship. For TOD designations, the beneficiary form on file with the transfer agent.
- 2
Fill in the template below
Replace each bracketed placeholder with the case-specific facts: decedent's full legal name as shown on the share certificates or DRS statement, date and place of death, the decedent's domicile state at death (the single state, not the residence list), the affiant's capacity (executor, administrator, surviving joint owner, TOD beneficiary), the issuing company name and CUSIP (if known), and the number of shares.
- 3
Identify the transfer agent and confirm its form
Each issuer assigns a transfer agent (Computershare, Equiniti, Broadridge, AST). Pull the most recent statement or proxy material to find the agent. The agent typically has its own affidavit form; the template below is the general industry-accepted version. Confirm the agent does not require a specific company-branded form before notarization.
- 4
Sign before a notary and obtain a Medallion Signature Guarantee
Do not pre-sign. The affiant signs in front of a notary who administers the oath and completes the jurat. Then, separately, take the signed affidavit to a Medallion-program institution (typically the affiant's bank or brokerage) for the Medallion Signature Guarantee stamp (STAMP, SEMP, or MSP). The Medallion stamp is required by the transfer agent and is distinct from the notary jurat.
- 5
Submit to the transfer agent with the package
Mail the affidavit, the certified death certificate (original with raised seal), the letters testamentary or letters of administration (if applicable), the share certificates (if physical) or DRS instruction (if book-entry), and the Stock Power form (signed by the affiant with Medallion). Transfer agents typically take six to ten weeks to reissue; expedite is available for a fee.
Why Transfer Agents Require It
The affidavit of domicile is an industry-mandated instrument, not a court-issued or statute-prescribed form. Transfer agents, brokerages, and the DTC/Cede & Co. custody chain refuse to release securities held in a deceased owner's name without it because the affidavit fixes which state's law applies to the transfer and indemnifies the agent against after-claims by another state asserting it was the actual domicile. The affidavit is the financial-industry analog to the court-supervised probate decree: it gives the transfer agent enough comfort to act without waiting for a full ancillary probate in the decedent's domicile state.
The affidavit's evidentiary weight comes from 28 U.S.C. Section 1746 (penalty-of-perjury declarations) and the underlying state-court perjury statutes. The Medallion Signature Guarantee adds a financial-industry layer of authentication: the Medallion institution (the affiant's bank or brokerage) guarantees the authenticity of the signature and assumes financial liability for forgery. Together, the notary jurat plus the Medallion plus the certified death certificate give the transfer agent the same risk profile as a probate decree for the limited purpose of releasing securities.
The affidavit is paired with several adjacent instruments in a typical estate transfer. The affidavit of death records the fact of death and the affiant's survivorship status; the certified death certificate proves the death itself; letters testamentary or letters of administration prove the executor's authority; the Stock Power form authorizes the actual transfer; and the affidavit of domicile fixes the controlling state law. All five travel together as a single submission package to the transfer agent.
The affidavit does not transfer the securities. The transfer happens by operation of law (joint tenancy survivorship, TOD beneficiary designation, or probate decree) and is then executed by the transfer agent through a book-entry change in the issuer's shareholder registry. The affidavit is one of the documentary prerequisites the transfer agent requires before making that change; without it, the agent simply will not move the shares.
Computershare, Equiniti, Broadridge: Agent-Specific Routing
The affidavit is required whenever securities or financial-account assets must move from a decedent's name to the surviving owner, beneficiary, or estate. The form below covers each category; transfer-agent-specific addenda (if any) are signed alongside.
Stock and bond transfer
Surviving joint owner, TOD beneficiary, or executor transfers stocks, bonds, mutual fund shares, or DRIP accounts from the decedent's name. The transfer agent requires the affidavit before reissuing certificates or making book-entry transfers.
Brokerage account release
Brokerage moves the decedent's account balance, securities, and cash to the surviving joint owner or estate. The custodian (DTC/Cede & Co.) requires the affidavit through the brokerage chain even for accounts held in street name.
Estate-tax domicile determination
Multi-state estates use the affidavit to fix the decedent's single state of domicile so only one state's inheritance or estate tax applies. New York Form TT-141A is the closest state-form analog and references domicile in the same way.
DRS and direct-registration shares
Shareholders holding shares directly with the issuer (Direct Registration System book-entry) submit the affidavit to the transfer agent to reissue the position in the new owner's name without a brokerage intermediary.
Confirm the transfer agent's specific form before notarization.
Some transfer agents (Computershare in particular) publish their own affidavit form and reject the industry-general version. Call the transfer agent or pull the agent's estate-services package before signing. If the agent requires a specific form, send the matter through /get-a-quote so an attorney can prepare the agent-specific package with the Medallion and supporting documents.
Transfer-Agent and Affidavit of Domicile Questions
Sourced from the People Also Ask box for affidavit of domicile, affidavit of domicile for stock transfer, and what is an affidavit of domicile.
What is an affidavit of domicile?
Who needs an affidavit of domicile?
Who fills out an affidavit of domicile?
Does an affidavit of domicile need to be notarized?
Why do financial institutions require an affidavit of domicile?
What is the difference between domicile and residence?
When is an affidavit of domicile required for stock transfers?
How do you determine domicile for estate tax purposes?
Securities Stalled at the Transfer Agent? Get an Attorney on the Package
Transfer agents reject affidavits over agent-specific form mismatches, missing Medallion guarantees, wrong DTC/Cede indemnity language, and unclear authority chains. An estate attorney pulls the agent's published estate-services package, drafts the affidavit to the agent's precise form, coordinates the Medallion through the affiant's bank or brokerage, and routes the Stock Power, death certificate, and letters testamentary as a single submission so the reissue moves the first time.