Small Estate Affidavit

State of
County of

I, , being duly sworn, state:

1. Decedent's name:
   Date of death:
   Decedent's address at time of death:
2. Decedent died on the date listed above, and I am:
   • ( ) The surviving spouse of the decedent
   • ( ) Other heir or claimant:
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 in any jurisdiction.
5. The total value of the decedent’s estate, wherever located, minus any liens or encumbrances, does not exceed $ .
6. The estate is composed of the assets listed below:

   Description of Asset	Value

Surviving Spouse Clause

I, , am the surviving spouse of the decedent named above. I am entitled to claim assets of the estate to the extent permitted by law, and consent to the distribution of assets as set forth in this affidavit.

Heirs or Beneficiaries

Name	Relationship	Share (%)

Affiant's Oath

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

Date:

Affiant’s Signature

Notary Public

Subscribed and sworn to (or affirmed) before me on this day of , 20.
Notary Public:
My commission expires: