STATE OF NORTH CAROLINA

COUNTY OF [County Name]

Introduction:

I, [YOUR NAME], being duly sworn, declare and affirm under oath that:

Statement of Facts:

1. The decedent, whose full name was [Name of the Deceased], was born on [DOB] and passed away on [DOD].

2. At the time of death, their last known residential address was [Address].

3. This information is provided to affirm the domicile of the decedent for purposes related to their estate and its proceedings under the laws of the State of North Carolina.

4. I, [YOUR NAME], hereby declare my relationship to the deceased, [Name of the Deceased], as [Relationship to the deceased].

5. My current residential address is [YOUR ADDRESS].

6. This affidavit is executed in my capacity as the [relationship to the deceased], providing necessary personal and relational details to support the verification of the decedent’s domicile as required for the administration and proceedings of their estate under North Carolina law.

Domicile Declaration:

I hereby affirm that the decedent was domiciled in the State of North Carolina, County of [County Name], at the time of their death. To the best of my knowledge, this had been the decedent's domicile for [Number of years/months] before their death, and they had no intention of changing their domicile.

Purpose of Affidavit:

This Affidavit is executed for the purpose of establishing the domicile of the deceased at the time of their death in connection with the disposition of the estate and for no improper purpose.

Acknowledgment:

I understand that this Affidavit is to be used to prove the last legal residence of the deceased for determining which state’s laws will govern the probate of their estate.

I swear (or affirm) that the information provided in this Affidavit is true and correct to the best of my knowledge, understanding, and belief.

Dated this [DAY] of [MONTH], [YEAR].

Signature:

[YOUR NAME]

Subscribed and sworn to (or affirmed) before me this [DAY] of [MONTH], [YEAR], by [YOUR NAME].

[NOTARY PUBLIC NAME]

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