Fill and Sign the Affidavit Personal Property Form

(TYPE OR PRINT IN BLACK INK) STATE OF NORTH CAROLINA Cou n ty IN T HE M A TT E R OF T HE ES T A T E OF: N am e , Stre e t Addre s s , C it y , State And Zip C ode O f D e c ede n t So c ial Se c u r ity N o. (La s t Four D i g it s ) C ounty O f D omi c ile At Time O f D eath File N o. In T he Ge ne ral Co u rt Of Jus t ice S u pe rior C o u rt Di v ision B e fo re T he C l e rk A FFID A VIT FOR COLLE C TION OF PE R SON A L P R OPE R TY OF D E C E D E N T (For Decedents Dying On Or After Jan. 1, 2012) IN T ES T A T E T ES T A T E G.S . 28 A -25-1; 28 A -25-1 . 1 D ate O f D eath D ate O f W ill Pla c e O f D eath (If D ifferent From C ounty O f D omi c ile) N am e , Stre e t Addre s s , PO Bo x , C it y , State And Zip Code O f Affiant 1 N am e , Stre e t Addr e ss , PO Bo x , C it y , State And Zip Code O f Affiant 2 Teleph on e N o. Teleph on e N o. Leg a l R e s iden c e ( C ount y , State) Leg a l R e s iden c e ( C ount y , State) N am e , Stre e t Addre s s , PO Bo x , C it y , State And Zip Code O f Attorney Attorney Bar N o. Teleph on e N o. I, the undersigned affiant, being first duly sworn, say that: 1. I am an heir. an executor named in the will. a de v isee named in the will. the p ublic administrator a creditor of the decedent. I am not d i squalified under G.S. 28A-4-2. 2. At least thirty (30) days have passed since the date of the de c edent's death. 3. The decedent died intestate. testate. 4. (a) The decedent died on or after 10/1/09 and the v alue of all personal property owned by the decedent less liens and emcumbrances thereon, and less the spousal allowance under G.S. 30-15, does not exceed $20,000. (b) I am the surviv i ng s pouse and sole heir devisee of the decedent, the decedent died on or after 10/1/09, and the value of all personal property, less liens and encumbrances thereon, and less the spousal allowance under G.S. 30-15, does not exceed $30,000. 5. (Check if decedent died testate.) Decedent's will dated as shown abo v e has been p robated in each county in which is located any real property owned by the decedent as of the date of death; and a certi f ied copy of the decedent's will is attached to this Affida v it. 6. No application or petition for appointment of a pe r sonal representative is pending or has been g r anted in any jurisdiction. 7. After diligent inquiry, I have determ i ned that the persons listed below are all the persons entitled to share in the de c edent's estate. ( If there is a court-appointed guardian for any such person(s), li s t the guardian's na m e and address on an a ttach m ent.) NAME AGE RELATIONSHIP MAILING ADDRE S S AO C - E -203 B , R e v . 5 / 12 Original - File Copy - Fiduciary Copy - Clerk Mails Copy To Each Person Listed In Item No. 7 (O v er) © 2012 A d m inis t ra t i v e Off ice o f t he C our t s P R E LI M IN A RY I NVE N T ORY (Give values as of date of decedent's deat h . Continue on separate a ttach m ent if necessary.) P A RT I . P RO PE R T Y OF T HE ES T A T E 1. Accounts in sole name of decedent (List bank, et c ., each account no. and balance.) 2. Joint accounts w ithout right of survivorship (List bank, etc., each account n o ., balance and joint owners.) % O w ned B y D e c . % O w ned B y D e c . % O w ned B y D e c . % O w ned B y D e c . Est. M arket Value $ 3. Stocks/bonds/securities in sole name of decedent or jointly owned w ithout right of sur v i v orship............................................................ . . . .............................. % O w ned B y D e c . 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Cash and undeposited checks on hand............................ .. ........................................................................... Household furnishings........................................................ . ... ........................................................................ Farm products, livestock, equip m ent and tools.............................................................................................. Vehicles (include or attach descriptions) Interest in partnership or sole proprietor businesses...................................................................................... Insurance, Retirement Plan, I.R.A., etc., payable to Estate........................................................................... Notes, judgments, and other debts due decedent.......................................................................................... Miscellaneous personal property......................................... ... ........................................................................ Real estate willed to the Estate.......................................... .... ...................... $ Estimated annual income of Estate.................................... .... ........................................................................ (Base bond on this a m ou n t, if applicable.) T O T A L P A RT I . $ P A RT II. P RO PE R T Y WHICH C A N BE A D DE D T O ES T A T E IF N EE D E D T O P A Y CL A I M S 1. Joint accounts with right of sur v ivorship (List bank, etc., each account n o ., balance and joint owners.) $ 2. Stocks/bonds/securities registered in beneficiary form and immediately transferred on death or jointly owned with right of sur v ivorship .......................................... ... ........................................................................ 3. Other personal property reco v erable G.S. 28A-15-10)................................................................................... 4. Real estate owned by decedent and not listed elsewhere (attach description ) ................................................. T O T A L P A RT II . $ P A RT III. O T H E R PROPE R T Y 1. There is i s not entireties real estate owned by decedent and spouse .......................................... 2. There are are not Insurance, Retirement Plan, I.R.A., accounts, etc., payable to named beneficiaries........................................................................ ... ......................................................................... Sig na tu r e O f Co ll e c tor By Af f id a v it 1 Sig na tu r e O f C o ll e c tor By Af f id a v it 2 N ame ( T y pe O r P r int) N ame ( T y pe O r P r int) S WOR N / A FFIR M E D A ND SU BS C R IB E D T O B E FORE M E S WOR N / A FFIR M E D A ND SU BS C R IB E D T O B E FORE M E D ate Sig na tu r e O f Pe r s on Au t h or i z ed To Admini s ter Oa ths D ate Sig na tu r e O f Pe r s on Au t h or i z ed To Admini s ter Oa ths D e pu ty C SC A ss i s ta n t C SC C le r k O f Su per ior C o ur t D ate Co mmi ss ion E x pi r es N ota r y D e pu ty C SC A ss i s ta n t C SC C le r k O f Su per ior C o ur t D ate C ommi ss ion E x pi r es N ota r y SE A L C o un ty W h er e N ota r i z ed SE A L C ER T IFIC A T ION C o un ty W h er e N ota r i z ed I certify that the foregoing is a true and accurate copy as taken from and compared with the original on record in this office. D ate Sig na tu r e D e pu ty C SC A ss i s ta n t C SC C le r k O f Su per ior C o ur t SE A L NOTE: This Af f id a v it f or Co ll e c tion of Pe r s o na l Pr oper ty of D e c e den t a u th or i z es t he n a med c o lle c tor by a f f id a v i t t o r e c ei v e a n d a d mini s ter ALL o f t he p er s o na l p r o per ty b e lo ng ing t o t he n a med d e c e den t p ur s u an t t o G .S. C h ap ter 2 8 A, A r ti c le 2 5 . AO C - E -203 B , Sid e Two , Rev . 5/1 2 © 2012 A d m inis t ra t i v e Off ice o f t he C our t s