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Heirship AffidavitPrepared by:If recorded, return to:))))))))))-------------------above this line for official use only----------------- HEIRSHIP AFFIDAVIT (Heirship of _______________________________ Deceased) STATE OF CONNECTICUT COUNTY OF _____________))BEFO RE M E, th e unders ig ned au th ority , on th is day pers o nally ap peare d _____________________________, (" A FF IA N T") w ho is p ers o nally k now n to m e (o r, if n ot b ein g p ers o nally k now n to m e, d id c o nfir m h is /h er id en tity pre se n tin g _ _________________ ____ a s id en ti f ic atio n ( i.e . d riv ers lic en se # ), a n d a p pearin g to b e f u lly c o m pete n t a n d of s u ffic ie n t a g e, u pon b ein g d uly s w orn , s ta te d u pon A ffia n t's o ath t h e f o llo w in g:1. My nam e is _______ _________________________________ (in se rt nam e of affia n t) , an d I liv e at __ _________________ ____________________________ _________ ( in se rt a d dre ss o f a ffia n t's r e sid en ce). I am p ers o nally fa m ilia r w ith th e fa m ily an d m arita l h is to ry o f _ ___________________________________ ("D eced en t" ) ( in se rt n am e o f d eced en t) , a n d I h av e p ers o n al k now le d ge o f t h e f a cts s ta te d i n t h is a ffid av it.2 . I k new d eced en t fro m _ ______________________ (in se rt d ate ) u ntil _ ________________________ (in se rt da te ). I was personally well acquainted with the named decedent during his/her lifetime.3. The D eced en t die d on _________________________________________ (in se rt date of death ) at th e fo llo w in g p la ce o f d eath : _____________________________________(C ity ), _ _____________________, (C ounty ), _ __________ ______________ (S ta te ) (in se rt p la ce o f d eath ). At th e tim e o f d eced en t's d eath , de ced en t's re sid en ce ad dre ss was __ _________________ ____________________________ _____________________ ( S tr e et) , __ _________________ ______________(C ity ), C onnectic u t, _________________ (Z ip ).( in se rt ad dre ss o f de ced en t's r e sid en ce).4. I was well acquainted with the family and near relatives of the said decedent, and with all those who would under the laws of the State of Connecticut, be his/her heirs. The following statements and the information contained herein, including my answers to named questions below, are based upon my personal knowledge and are true and correct.QUESTION 1 - Did the decedent leave a will? ANSWER: YES/NOQUESTION 2 - If the decedent left a will, has the will been admitted to probate? ANSWER: YES/NO/NA. If YES, at what place, and when?ANSWER: _________________COUNTY, Connecticut, _____________ CAUSE NUMBER______________ DATEQUESTION 3 - If the decedent left no will, has an administrator or personal representative been appointed for the estate of said deceased? ANSWER: YES/NO Heirship AffidavitQUESTION 4 - If an administrator or personal administrator has been appointed, give the County in which the proceedings are pending, and the name and address of the administrator or personal representative. ANSWER: COUNTY CAUSE NUMBER NAMEADDRESS QUESTION 5 - Give the name and address of the surviving widow or widower of decedent.ANSWER: NAMEADDRESS If not now living, state date of death:QUESTION 6 - If the decedent was married more than once, give the name(s) of the former husband or wife, and state whether said former spouse is dead or divorced.ANSWER: NAME STATUS (Dead or Divorced) QUESTION 7 - Give the names and places of residence of all the surviving children of deceased, together with the other information called for:ANSWER: (Give names of surviving children only) NAME OF CHILD ADDRESS DATE OF BIRTHIF NOT LIVING DATE OF DEATHHUSBAND OR WIFE NAME Heirship AffidavitQUESTION 8 - Give the name and address of any deceased children of the decedent, together with the other information called for:ANSWER: NAME OF CHILD DATE OF BIRTHDATE OF DEATH SURVIVING HUSBAND OR WIFE NAMEDATE OF DEATH OF SPOUSE, IF APPLICABLE QUESTION 9 - Give the names and addresses of the children of any deceased son or daughter of the decedent:ANSWER: NAME OF CHILD ADDRESS OF IF NOT LIVING DATE OF DEATHDATE OF BIRTHNAME OF FATHER OR MOTHER QUESTION 10 - Did the decedent have any adopted children, or step-children taken into his home?ANSWER: YES/NO. If yes, provide their names, ages and addresses below: NAMEADDRESS AGE Heirship AffidavitQUESTION 11 - Did the decedent have any unpaid debts? ANSWER: YES/NO. If yes, provide as nearly as possible the amount of the debt and creditor and whether such debt has since been paidANSWER: CREDITOR AMOUNT OF DEBT HAS DEBT NOW BEEN PAID QUESTION 12 - If the decedent left no children, then give below the names and addresses (together with other information called for), or his or her surviving father, mother, brothers, sisters:ANSWER:NAMERELATIONSHIPAGEADDRESS OR DATE OF DEATHQUESTION 13 - If the decedent left no children, spouse, mother, father, brother or sister, state all other known relatives:ANSWER: NAM E RELA TIO NSH IP A GE ADDRESS Heirship AffidavitQUEST IO N 1 4: D id t h e d eced en t o w n a n y r e al e sta te i n t h is S ta te :A N SW ER : Y ES/N OIf y es, l is tA ddre ss o r s h ort d esc rip tio n : _ ___ ________________________________________________________________ C ounty : _ ___________________ ____ A ddre ss o r s h ort d esc rip tio n : _ ___ __ _______________________ _______________________________________ C ounty : _ ___________________ ____ A ddre ss o r s h ort d esc rip tio n : _ ___ ________________________________________________________________ C ounty : _ ___________________ ____ A ddre ss o r s h ort d esc rip tio n : _ ___ ________________________________________________________________ C ounty : _ ___________________ ____ A ddre ss o r s h ort d esc rip tio n : _ ___ ________________________________________________________________ C ounty : _ ___________________ ____ QUESTION 15: What is your relationship to the deceased?ANSWER:DATED THIS THE ________ DAY OF _______________________, 20____. ___________________________________Signature of Affiant SWORN TO AND SUBSCRIBED before me this the _______ day of ______________, 20___. __________________________NOTARY PUBLIC My Commission Expires: ___________________