Small Estate Affidavit for Unclaimed Property

Decedent Information

Full Name of Decedent

Date of Death

Place of Death

Last Known Address

Affiant Information

Full Name

Relationship to Decedent

Phone Number

Address

Unclaimed Property Description

Type of Property Account/Claim Number or Other Identification

Heirs and Distributees

List all known heirs and their relationship to decedent

Affirmation

I, the undersigned, affirm that I am entitled to act as affiant for the estate of the above-named decedent, and that the estate meets all requirements for a small estate affidavit for unclaimed property under applicable state law.

I solemnly affirm under penalty of perjury that the foregoing is true and correct.

Signature of Affiant

Date