Small Estate Affidavit for Out-of-State Decedents

1. Decedent Information

Full Name of Decedent Date of Death State of Residence at Time of Death Decedent’s Address at Time of Death

2. Affiant Information

Full Name of Affiant Relationship to Decedent Affiant Address Affiant Phone Number

3. Estate Information

Total Value of Estate Located in This State List of Assets Located in This State Other Known Assets

4. Heirs/Beneficiaries

Name	Relationship	Share/Interest	Address

5. Debts and Liabilities

Known Debts or Liabilities

6. Affidavit Statement

I, the undersigned, declare under penalty of perjury that the foregoing is true and correct, that I am the proper person to execute this affidavit under the laws applicable, and that the estate qualifies for small estate procedures in this state pursuant to all relevant statutes.

7. Signatures

Affiant’s Signature Date Notary Public (if required)