Fill and Sign the Affidavit Collection Property Form

1 Prepared by, recording requested by and return to: Name: Company: Address: City: State: Zip: Phone: Fax: ------Above this Line for Official Use Only------- Affidavit for Collection of Property – Small Estate State of North Carolina County of _____________________________ I, _____________________________, upon being duly sworn, state on my oath that: 1. My post office address is: _____________________________ 2. My residence address is: _____________________________ 3. I am ( ) the public administrator, ( ) a creditor, ( ) an heir and successor to the decedent, ( ) the surviving spouse and sole heir of the decedent and am therefore entitled, either under the decedent’s will or under the provisions of the Intestate Succession Act, to all of the property of the decedent. All successors of the decedent, if any, including myself, and their relationship to the decedent, are as follows: Name/Relationship Address 4. The decedent's name is _____________________________. 5. The decedent’s residence at the time of death was _____________________________. 2 6. The date of the decedent's death was the _________ day of __________________________, 20_________. 7. Thirty (30) days or more have elapsed since the death of the decedent. 8. The place of death was _____________________________. 9. The decedent passed away ( ) with ( ) without a last will and testament. If a will exists: A. The decedent's will has been admitted to probate in the court of the proper county and a duly certified copy of the will has been recorded in each county in which is located any real property owned by the decedent at the time of his death, and B. That a certified copy of the decedent's will is attached to this affidavit as exhibit “A”. 10. ( ) The value of all of the personal property owned by the estate of the decedent, less liens and encumbrances, does not exceed ten thousand dollars ($20,000.00), or ( ) The affiant is the surviving spouse and sole heir of the decedent, not disqualified under G.S. 28A-4-2, and the value of the personal property owned by the estate of the decedent does not exceed twenty thousand dollars ($30,000). 11. That no application or petition for the appointment of a personal representative is pending or has been granted in any jurisdiction. 12. The following is a description of all real property, by tract, owned by the decedent at the time of the decedent’s death: _______________________________ 13. That the affiant has filed this petition in the office of the clerk of superior court for the County of _____________________________ and has paid the fee required by N.C.G.S. §7A- 307 in full. The foregoing statement is made under Penalty of Perjury. ________________________________________Signature of Affiant Acknowledgment of Individual STATE OF NORTH CAROLINA COUNTY OF _____________________________ I, a Notary Public, do hereby certify that _____________________________ (here give the name of the grantor or maker) personally appeared before me this day and 3 acknowledged the due execution of the foregoing instrument. Witness my hand and (where an official seal is required by law) official sealThis the ___________________ day of ___________________ (year). (Official seal.) ______________________________ Notary Public Printed Name: _________________ My Commission Expires: 4 Notes: The presentation of an affidavit as provided in subsection (a) of N.C.G.S. §28A-25-1(a) shall be sufficient to require the transfer to the Affiant or his designee of the title and license to a motor vehicle registered in the name of the decedent owner; the ownership rights of a savings account or share certificate in a credit union, building and loan association, or savings and loan association in the name of the decedent owner; the ownership rights in any stock or security registered on the books of a corporation in the name of the decedent owner; or any other property or contract right owned by the decedent at the time of his death.