Affidavit of Heirship

State of County of

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I, of legal age, residing at being duly sworn, state the following:

1. Decedent's Name
2. Date of Death
3. Place of Death (City and State)
4. Decedent's Residence at Time of Death
5. Relationship to Decedent
6. Names, relationships, and addresses of all known heirs:

   Name	Relationship	Address

7. Other information or remarks:

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Notary Public

Subscribed and sworn before me on Notary Public Signature My Commission Expires