Small Estate Affidavit for Insurance Proceeds

I, , being duly sworn, state as follows:

Date: Affiant's Address:

Decedent's Information

Full Name of Decedent: Date of Death: Last Address: Policy Number(s):

Affidavit Statement

1. The decedent died on the date above and was a resident of .
2. The total value of the entire estate, including insurance proceeds to be collected, does not exceed the limit for a small estate under state law.
3. At least days have passed since the decedent’s death.
4. No application or petition for the appointment of a personal representative is pending or has been granted.
5. The following people are entitled to payment of the insurance proceeds:

Names and Addresses of Heirs/Beneficiaries: Relationship to Decedent: Total Estate Value: Other Relevant Details:

Affiant's Signature

Signature:

Date:

Printed Name: Notary Public (if required):