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This is a Briggs Morgan form that can be used for Minnesota CLE.
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Print Form Clear Form STATE OF MINNESOTA COUNTY OF ___________________ ss. AFFIDAVIT OF DOMICILE I, ___________________________________________________________________, state: For Individual: 1. My address is: __________________________________________________________________________. 2. I am the Personal Representative of the Estate of _________________________________________________. or Surviving Joint Tenant, T.O.D. payee, or P.O.D. payee of ______________________________________ _________________________ who died on ____________________. For Corporate: 1. I am an officer, namely, ________________________________ of _________________________________ _______________________ a corporation organized under the laws of the State of ____________________, having its principal place of business at _______________________________________________________. 2. ___________________________________________________________________________ is the Personal Representative of the Estate of ______________________________________________________________, Decedent, who died on ____________________. For Both Individual and Corporate: 3. At the time of death of the Decedent the physical situs of ________ shares of ________________________ corporation _________ bonds of _________________________________________, was in the City of ____________________, County of ____________________, State of ____________________. 4. At the time of death the domicile (legal residence) of the Decedent was _____________________________. 5. The Decedent resided in the State of ____________________ for _________ years prior to death and was not domiciled in any other state within the United States at the time of death. 6. The last federal income tax return filed by the Decedent was for the year ______________, as a domiciliary of the State of ____________________. Dated: _____________________ ______________________________________ Affiant MNCLE © 2016 P086 1 Affidavit of Domicile NOTARIAL STAMP OR SEAL (OR OTHER TITLE OR RANK): Signed and sworn to (or affirmed) before me on __________________________________ by _____________________________________________, Affiant. _____________________________________________ Signature of Notary Public or Other Official MNCLE © 2016 P086 2 Affidavit of Domicile
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