Fill and Sign the Drivers License and Appearing to Be Fully Competent and of Sufficient Age Upon Being Duly Sworn Stated Upon Affiants Oath the Form

Heirship Affidavit Prepared by: If recorded, return to: ) ) ) ) ) ) ) ) ) ) -------------------above this line for official use only----------------- HEIRSHIP AFFIDAVIT (Heirship of _______________________________ Deceased) STATE OF CONNECTICUT COUNTY OF _____________ ) ) BEFORE ME, the undersigned authority, on this day personally appeared _____________________________, ("AFFIANT") who is personally known to me (or, if not being personally known to me, did confirm his/her identity presenting ______________________ as identification (i.e. drivers license #), and appearing to be fully competent and of sufficient age, upon being duly sworn, stated upon Affiant's oath the following: 1. My name is ________________________________________ (insert name of affiant), and I live at ________________________________________________________ (insert address of affiant's residence). I am personally familiar with the family and marital history of ____________________________________ ("Decedent") (insert name of decedent), and I have personal knowledge of the facts stated in this affidavit. 2. I knew decedent from _______________________ (insert date) until _________________________ (insert date). I was personally well acquainted with the named decedent during his/her lifetime. 3. The Decedent died on _________________________________________ (insert date of death) at the following place of death: _____________________________________(City), ______________________, (County), _________________________ (State) (insert place of death). At the time of decedent's death, decedent's residence address was ____________________________________________________________________ (Street), _________________________________(City), Connecticut, _________________ (Zip).(insert address of decedent's residence). 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/NO QUESTION 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 ______________ DATE QUESTION 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 Affidavit QUESTION 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 NAME ADDRESS QUESTION 5 - Give the name and address of the surviving widow or widower of decedent. ANSWER : NAME ADDRESS 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 BIRTH IF NOT LIVING DATE OF DEATH HUSBAND OR WIFE NAME QUESTION 8 - Give the name and address of any deceased children of the decedent, together with the other information called for: ANSWER : Heirship Affidavit NAME OF CHILD DATE OF BIRTH DATE OF DEATH SURVIVING HUSBAND OR WIFE NAME DATE 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 DEATH DATE OF BIRTH NAME 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: NAME ADDRESS AGE QUESTION 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 paid ANSWER : CREDITOR AMOUNT OF DEBT HAS DEBT NOW BEEN PAID Heirship Affidavit 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: NAME RELATIONSHIP AGE ADDRESS OR DATE OF DEATH QUESTION 13 - If the decedent left no children, spouse, mother, father, brother or sister, state all other known relatives: ANSWER: NAME RELATIONSHIP AGE ADDRESS Heirship Affidavit QUESTION 14: Did the decedent own any real estate in this State: ANSWER: YES/NO If yes, list Address or short description : ____________________________________________________________________ County: ________________________ Address or short description : ____________________________________________________________________ County: ________________________ Address or short description : ____________________________________________________________________ County: ________________________ Address or short description : ____________________________________________________________________ County: ________________________ Address or short description : ____________________________________________________________________ County: ________________________ 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: ___________________