Small Estate Affidavit

State of County of

Estate of (Decedent’s Name):

Affiant Information:

Name:

Address:

Phone:

Relationship to Decedent:

Date of Decedent’s Death:

List of Known Heirs/Beneficiaries:

Assets of the Estate:

Description	Location	Value

Debts and Liabilities:

Affiant Statement:

I, the undersigned, swear or affirm that the foregoing information is true and correct, that I am qualified under state law to file this affidavit, and that the estate described qualifies as a small estate.

Affiant’s Signature:

Date:

Notary Public:

My Commission Expires: