Complete Form ET-141 if it is claimed that the decedent was not domiciled in New York State at the time of death. RULE 2106: Affirmation of truth of statement.1. Gather the decedent's personal details. Submit the Declaration of Domicile to each applicable utility provider or rural electric cooperative, not to the Department of Revenue. Join the Clark Business Community! Please complete this form to have your business included in a list sent to new residents. Visit a store or an organization that provides legal forms; or preferably consult your own personal attorney.