Affidavit of Small Estate

State of

County of

I, (Affiant's Name):

Being first duly sworn, depose and say:

1. The Decedent, (Name of Decedent):

Died on (Date of Death):

At (Place of Death):

And was a resident of (Address):

2. The value of the entire estate does not exceed:

3. Description of assets (list below):

4. Names and addresses of all known heirs and their relationship to the decedent:

5. No application or petition for the appointment of a personal representative is pending or has been granted in any jurisdiction.

6. The undersigned requests that the property be paid, delivered, or transferred to the persons entitled thereto pursuant to law.

Signature of Affiant

Date

Notary Public

My Commission Expires