STATE OF MISSOURI
COUNTY OF [COUNTY NAME]

Introduction:

I, [YOUR NAME], of [YOUR ADDRESS], in the County of [County Name], State of Missouri, being duly sworn, depose and say:

Statement of Facts:

1. The decedent, [Decedent’s Name], passed away on [Date of Death].

2. At the time of death, [Decedent’s Name] resided at [Decedent’s Last Residential Address], located in the city of [City Name], county of [County Name], within the State of Missouri.

3. This address was recognized as the legal and primary residence of the decedent, affirming their domicile within the state at the time of their passing.

4. I am the [Relationship to the Decedent], and I have personal knowledge of the decedent’s domicile at the time of their death.

5. It has come to my attention that the domicile of [Decedent’s Name] at the time of their death is contested, with claims that their domicile was outside of Missouri.

6. I hereby affirm that [Decedent’s Name] was a legal resident and domiciled in the State of Missouri at the time of their death. This affirmation is based on the following evidence:

   • Evidence 1: [Description of evidence supporting Missouri domicile, e.g., property ownership in Missouri].

   • Evidence 2: [Description of additional evidence, e.g., Missouri driver’s license, voter registration].

   • Further Evidence: [Any additional evidence or details, e.g., social ties, community involvement in Missouri].

Purpose of Affidavit:

This affidavit is made for the purpose of being submitted to [Relevant Legal Entity or Financial Institution] to assert the Missouri domicile of [Decedent’s Name] in light of the contested claims regarding their domicile.

Legal Acknowledgment:

I understand that this affidavit is made under oath and subject to the penalties of perjury under the laws of the State of Missouri.

Executed on this day of [Date], [Year].

Signature:

[YOUR NAME]

Subscribed and sworn to before me this [Day] of [Month], [Year].

[Notary Public’s Name]
Notary Public, State of Missouri

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