Small Estate Affidavit Form
for Retirement Accounts
Decedent Information
Full Name of Decedent
Social Security Number
Date of Death
Affiant Information
Your Full Name
Relationship to Decedent
Mailing Address
Retirement Account Information
Institution Name
Account Number
Type of Retirement Account
Estate Information
Total Value of Decedent’s Entire Estate
State Law Under Which Affidavit is Made
Heirs/Beneficiaries
List all heirs and their relationship to the decedent (one per line)
Affirmations
I am entitled to payment or delivery of the described property as allowed by state law.
No application or petition for the appointment of a personal representative is pending or has been granted.
The estate qualifies as a small estate under applicable law.
Signature of Affiant
Date
Notary Public (if required)
Date