Fill and Sign the In the County Clerks Record Form

53-111-A (Rev.4-07/3) AFFIDAVIT OF HEIRSHIP Link to 53-111-B THIS AFFIDAVIT MUST BE FILED IN THE COUNTY CLERK’S RECORD. Reported owner name: Claim number: This Affidavit must be completed by a third disinterested party (Affiant) who will not benefit from the decedent’s estate. Do not complete this form if the decedent left a will that was probated in court or there has been some other type of court determination to the estate. Affidavit of facts concerning the identity of Heirs for the Estate of: _____________________________________________ Before me, the undersigned authority, on this day personally appeared: ________________________________________ (“Affiant”) who, being first duly sworn, upon his/her oath states: 1. My name is: ___________________________________________________________________________________ . I live at: _______________________________________________________________________________________ I am personally familiar with the family and marital history of: ______________________________________________ (Decedent), and I have personal knowledge of the facts stated in this Affidavit. 2. I knew the decedent from ________________ until ________________ Decedent died on ______________________ . Decedent’s place of death: ________________________________________________________________________ CITY STATE COUNTY At the time of decedent’s death, decedent’s residence was: ________________________________________________________________________ CITY STATE COUNTY 3. Provide the following information on the deceased’s marital history: (If never married, please state that below.) NAME OF SPOUSE DATE OF MARRIAGE DATE OF DIVORCE DATE OF SPOUSE’S DEATH 4. Provide the following information on the deceased’s natural born and adopted children: (If there are none, please state that below. If additional space is needed, please provide information as an attachment.) NAME OF CHILD/ CURRENT ADDRESS DATE OF BIRTH NAME OF CHILD’S OTHER PARENT DATE OF CHILD’S DEATH 5. Provide the following information on the deceased’s grandchildren, born only to the deceased children in Item 4, above: (If there are none, please state that below.) NAME OF CHILD/ CURRENT ADDRESS DATE OF BIRTH NAME OF GRANDCHILD’S DECEASED PARENT 6. If the decedent never married and did not have any children, provide the following information on the deceased’s parents: DECEASED’S PARENTS MOTHER FATHER PARENT’S NAME/ CURRENT ADDRESS PARENT’S DATE OF DEATH Form 53-111-A (Back)(Rev.4-07/3) Reported owner name: Claim number: 7. Provide the following information on the deceased’s brothers and/or sisters: (If there are none, please state that below.) NAME OF CHILD/ CURRENT ADDRESS DATE OF BIRTH BROTHER’S OR SISTER’S DATE OF DEATH 8. Provide the following information on the deceased’s nieces and/or nephews born only to the deceased brothers/sisters in Item 7, above: (If there are none, please state that below. If additional space is needed, please provide information as an attachment.) NAME OF NIECE OR NEPHEW/ CURRENT ADDRESS DATE OF BIRTH NAME OF NIECE OR NEPHEW’S DECEASED PARENT Signed this ____ day of ____________________, ____________. _____________________________________________________________________________________ (SIGNATURE OF AFFIANT) State of _________________________ County of _______________________ Sworn to and subscribed to before me on _________________________________________________ (DATE) by ________________________________________________________________________________ (NAME OF AFFIANT) _____________________________________________________________________________________ (NOTARY SIGNATURE) (Notary Seal) My commission expires: _____ day of __________________, _______. THIS AFFIDAVIT MUST BE FILED IN THE COUNTY CLERK’S RECORD.