SMALL ESTATE AFFIDAVIT

FOR COLLECTION OF DECEDENT'S PROPERTY

I (affiant’s name), being first duly sworn upon oath, declare that
the following statements are true:

1. Decedent, , died on the day of , 20

in the County of , in the State of . A copy of Decedent’s
death certificate will be filed alongside this Affidavit.

2. My name is , of [Address],
[State].

3. More than days have elapsed since Decedent’s death.

4. I am either an heir of the Decedent, and the Decedent left no will, or I am a named
devisee of the Decedent in the decedent’s will.

5. No administration is pending or has been granted in Decedent’s estate and none appears
necessary.

6. The Descendant’s estate value of assets exceeds the estate’s presently known liabilities.

7. The value of the entire assets of the estate of Decedent, not including homestead and
exempt property, does not exceed the limit of $ set by the State of
.

8. At time of signing, there is no reasonable expectation that a probate of the Descendant’s

estate is soon to commence.

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 9. All assets of the Decedent’s estate and their values are listed here.

Description of Asset(s) Additional information

List with enough detail to identify
If exempt property, so indicate.
exactly what the asset is. For
If decedent was married, indicate:
example, give bank name and last
1. whether each asset was community or separate property,
four digits of an account number; Value and
give life insurance company name;
2. facts that explain why the asset was community or
give description of car plus VIN
separate
number; give address & legal
description of real property. Use additional pages as necessary.

$ _______

$ _______

$ _______

$ _______

$ _______

$ _______

$ _______

$ _______

$ _______

$ _______

$ _______

$ _______

(Continue list as necessary. If list is continued on another page, please note.)

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10. All liabilities/debts of the Decedent’s estate and their values are listed here. The affidavit
must list all of Decedent’s debts and other liabilities including all credit card balances,
doctor and hospital bills, utility bills, etc. – everything owed by Decedent or Decedent’s
estate and not paid off.
- If none, write “none.”
- If funeral debts or attorney’s fees and expenses will be paid from estate assets, list
them here.
Description of Liabilities / Debts: Balance Due
List with enough detail to identify the creditor & any account.

(Continue list as necessary. If list is continued on another page, please note.)

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If you did not list attorney’s fees as a liability above but one or more distributees have paid or
will pay attorney’s fees for this small estate affidavit, indicate the amount of those fees here:
$________________. Also indicate who has paid or will pay the fees:
_______________________________________________.

11. The following facts regarding Decedent’s family history show who is entitled to what
share of Decedent’s estate, to the extent that the assets of Decedent’s estate, exclusive
of homestead and exempt property, exceed the liabilities of Decedent’s estate. [Put
check marks in the appropriate small boxes, and provide additional information as
indicated.]

Family History #1: Marriage.

 On the date of Decedent’s death, Decedent was a single person.
OR
 On the date of Decedent’s death, Decedent was married to
__________________________. The date they were married:
__________________________________.

Family History #2: Children.

 Decedent had no children by birth or adoption, and Decedent did not take any children
into Decedent’s home to raise as a child. (Skip to Family History #4 if you check this
box.)
OR
 The following children were born to or adopted by Decedent. List all children, whether
or not the child is still alive and whether or not parental rights were later terminated. If
parental rights were terminated for any child, give details on separate page(s).
Child’s name Birth date, if Name of child’s other parent
known

(Continue list as necessary. If list is continued on another page, please note.)

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Family History #3: Children, part 2. Answer if Decedent had any
children.
 All of Decedent’s children, by birth or adoption, were alive when Decedent died.
OR
 The following of Decedent’s children, by birth or adoption, died before the Decedent’s
death and were survived by children (or grandchildren or great-grandchildren):
Name of deceased child Names of all children of the deceased child
Date
(followed by the name of the (if any of these children died before Decedent, use a
child
deceased child’s other parent separate page to give date of death, plus names & birth
died dates of all grandchildren)
in parentheses)

(Continue list as necessary. If list is continued on another page, please note.)

AND/OR
 The following of Decedent’s children, by birth or adoption, died before the Decedent’s
death and were not survived by any children, grandchildren, or great-
grandchildren:
Name of deceased child Date child died

(Continue list as necessary. If list is continued on another page, please note.)

Family History #4: Parents.

 The Decedent was survived by both parents, ______________________________
(mother) and ______________________________ (father).
OR
 Decedent was survived by only one parent, ______________________________.
Decedent’s other parent, ______________________________, died on
________________.
OR
 Both of Decedent’s parents died before Decedent’s death.

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Family History #5: Sisters and Brothers.
The following information about Decedent’s sisters and brothers is not needed if Decedent
was survived by both parents or by children, grandchildren, or great-grandchildren.
 The following are all of Decedent’s brothers and sisters who were alive on the date
Decedent died, including half-brothers and half-sisters who were born to either of
Decedent’s parents. If none, write “none.” If any of the following are now deceased,
indicate date of death.
Name of brother or sister State whether full or half-sibling Birth date

(Continue list as necessary. If list is continued on another page, please note.)

AND
 The following of Decedent’s brothers and sisters (including half-brothers and half-
sisters who were born to either of Decedent’s parents) died before Decedent’s
death. If none, write “none.”
Name of deceased Names of all children of the deceased
Full or Birth dates of
brother or sister brother or sister (nephews and nieces
half nieces &
(followed by the date of of Decedent) that were alive on the date
sibling? nephews
death in parentheses) Decedent died

(Continue list as necessary. If list is continued on another page, please note.)

Family History #6: Other.

Fill out a separate page (or pages) if Decedent was survived by none of the following:
spouse, child, grandchild, parent, brother, sister, half-brother, half-sister, niece, or
nephew. If Decedent was survived by none of the above, list all of the surviving relatives
of Decedent on a separate page. Specify Decedent’s family history with respect to each of
the survivors, giving sufficient detail about names, birth dates, death dates, and
relationships to explain how each survivor is related to Decedent.

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HEIRS OR DISTRIBUTEES OF THE DECENDENT.
12. Based on the family history given in this Affidavit, the following chart lists all of the
Decedent’s heirs at law, together with their fractional interests in Decedent’s estate:
Share of
For each Distributee, list: Share of Share of decedent’s
separate
1. Name separate real community property
personal
2. Address property (fill out this column if
property
3. Telephone number (always fill out decedent was
(always fill out
4. Email address this column) married)
this column)

(Continue list as necessary. If list is continued on another page, please note.)

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SIGNATURE OF AFFIANT (DISTRIBUTEE)

STATE OF §

COUNTY OF §
I am an Affiant in the Estate of , Deceased. I
swear or affirm that I have personal knowledge of the facts stated in the foregoing Affidavit and
that the facts contained in the Affidavit are true and complete to the best of my knowledge.

Affiant's printed name Affiant’s signature

SWORN TO AND SUBSCRIBED before me by [name of Affiant],

an Affiant, on this day of , 20 .

(SEAL)
Notary Public, State of

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AFFIDAVITS AND SIGNATURES OF TWO (2) DISINTERESTED WITNESSES
STATE OF §

COUNTY OF §
I have no interest in the Estate of , Deceased,
and am not related to Decedent under the laws of descent and distribution of the State of
. I swear or affirm that the facts contained in this Affidavit regarding family history,
assets, and liabilities are true and complete to the best of my knowledge.

Disinterested Witness’s printed name Disinterested Witness’s signature

SWORN TO AND SUBSCRIBED before me by [name of

witness], a disinterested witness, on this the day of , 20 .

(SEAL)
Notary Public, State of

STATE OF §

COUNTY OF §
I have no interest in the Estate of , Deceased,
and am not related to Decedent under the laws of descent and distribution of the State of
. I swear or affirm that the facts contained in this Affidavit regarding family history,
assets, and liabilities are true and complete to the best of my knowledge.

Disinterested Witness’s printed name Disinterested Witness’s signature

SWORN TO AND SUBSCRIBED before me by [name of

witness], a disinterested witness, on this the day of , 20 .

(SEAL)
Notary Public, State of

Prepared in the Law Office of:

[Attorney signature]

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