STATE OF NEW HAMPSHIRE

COUNTY OF [County Name]

Introduction:

I, [Full Name of Executor], residing at [Executor's Full Address], being duly sworn, depose and say:

Statement of Facts:

1. I am the legal executor/administrator of the estate of [Deceased's Full Name], hereinafter referred to as the Decedent, who passed away on [Date of Death], as evidenced by the attached certified copy of the death certificate.

2. To the best of my knowledge and belief, at the time of death, the Decedent was a legal resident of the State of New Hampshire, residing at [Decedent's Address].

3. The purpose of this affidavit is to establish the domicile of the Decedent at the time of death for the purpose of claiming benefits, including but not limited to life insurance and retirement accounts, that require validation of the Decedent’s domicile.

4. I affirm that the Decedent had not changed their domicile or residence from the State of New Hampshire to another state or country at any time before their death.

5. This affidavit is executed to induce [Name of the Institution, e.g., insurance company, financial institution] to release the benefits accruing to the estate or beneficiaries of the Decedent.

Declaration:

I understand that a false statement made herein could subject me to penalties under the law.

Executed on this [DAY] of [MONTH], [YEAR], at [City, State].

Signature:

[YOUR NAME]

Sworn to and subscribed before me this [DAY] of [MONTH], [YEAR].

[Notary Public Name]

State of New Hampshire

Attachments:

• Certified Copy of Death Certificate

• Proof of Executorship/Administration

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