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Small Estate Affidavit 02

The Small Estate Affidavit form is used to declare that the gross probate estate does not exceed $50,000 and that 45 days have passed since the decedent's death. The affiant must provide information about the decedent, the estate, and the beneficiaries, and certify that no personal representative has been appointed. Additionally, the form requires the disclosure of Social Security Numbers as mandated by federal law.

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15 views1 page

Small Estate Affidavit 02

The Small Estate Affidavit form is used to declare that the gross probate estate does not exceed $50,000 and that 45 days have passed since the decedent's death. The affiant must provide information about the decedent, the estate, and the beneficiaries, and certify that no personal representative has been appointed. Additionally, the form requires the disclosure of Social Security Numbers as mandated by federal law.

Uploaded by

ebonyeidi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SMALL ESTATE AFFIDAVIT ($50,000)

State Form 54985 (R3 / 4-18)

* This agency is requesting disclosure of Social Security Numbers in accordance with I.C. 4-1-8-1; disclosure is mandatory under federal law, and this form will not be
processed without it. See 20 C.F.R. § 603.22; 42 C.F.R. § 435.960.

DECEDENT INFORMATION
Name Social Security Number * Date of death (mm,dd,yyyy)

Address (number and street, city, state, and ZIP code)

Comes now , the affiant herein and pursuant to I.C. 29-1-8-1, being duly sworn, says:
(1) The value of the gross probate estate, wherever located (less liens and encumbrances), does not exceed fifty thousand dollars ($50,000.00).
(2) Forty-five (45) days have elapsed since the death of the decedent.
(3) No application or petition for the appointment of a personal representative is pending or has been granted in any jurisdiction.
(4) The following person(s) are entitled to the portion of the decedent’s account listed below. (Please attach additional pages if necessary.)
Name Portion of account

Address (number and street, city, state, and ZIP code)

Name Portion of account

Address (number and street, city, state, and ZIP code)

(5) I have notified each person identified in this affidavit of my intention to present this affidavit.
(6) I am entitled to payment or delivery of the property on behalf of each person identified in this affidavit.
Signature Date (mm,dd,yyyy)

Printed name Social Security Number * Date of birth (mm,dd,yyyy)

Address (number and street, city, state, and ZIP code)

CERTIFICATION OF NOTARY PUBLIC

STATE OF

SS:

COUNTY OF

Subscribed and sworn to me, a notary public, in and for the state and county named.
Signature of notary public Printed name of notary public

County of residence Date commission expires (mm,dd,yyyy)

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