Fill and Sign the Hawaii Estate 497304583 Form

SMALL ESTATE AFFIDAVIT Collection of Personal Property Hawaii Revised Statues Section 560:3-1201 State of Hawaii County of __________________ I, ____________________________________ , upon duly sworn, state on my oath that: 1. My post office address is: ______________________________ Street Address ______________________________ City, State, Zip Code 2. My residence address is: ______________________________ Street Address ______________________________ City, State, Zip Code 3. I am a successor to the decedent identified below as defined in H.R.S. 560:1-201. All successors, including myself, of the decedent are listed as follows: Name Address: City: State: Zip Code: DOB: (minors only) Share of Estate: Name Address: City: State: Zip Code: DOB: (minors only) - 1 - Share of Estate: Name Address: City: State: Zip Code: DOB: (minors only) Share of Estate: Name Address: City: State: Zip Code: DOB: (minors only) Share of Estate: 1. The decedent's name is: ____________________________________ . 2. The date of the decedent's death was ________________________ , and I have attached a copy of the death certificate hereto. 3. That the gross value of the decedent’s estate in does not exceed one-hundred thousand Dollars ($100,000.00). 4. That no application or petition for the appointment of a personal representative is pending or has been granted in any jurisdiction. THE FOREGOING STATEMENT IS MADE UNDER THE PENALTIES OF PERJURY. ________________________________________ Signature of Affiant STATE OF HAWAII COUNTY OF __________________ - 2 - On this ______ day of __________________ , 20 _____ , before me personally appeared ______________________________ , to me known to be the person (or persons) described in and who executed the foregoing instrument, and acknowledged that he/she/they executed the same as his/her/their free act and deed. ______________________________ Notary Public ______________________________ Print Name My Commission Expires: __________________ - 3 -