Fill and Sign the Indiana Small Estate Affidavit for Estates under 50000 Form

          SMALL ESTATE AFFIDAVIT ($50,000) State Form 54985 ( R3 / 4-1 8) INDIANA DEPARTMENT OF WORKFORCE DEVELOPMENT 10  N.  Senate  Ave.,  Indianapolis,  IN   46204   Telephone:   (800 ) 891 ‐6499   Fax:   (317)  23 4‐4098   E -mail:   specialclaims @dwd.in.gov   Website:   www.in.gov/dwd/   * This agency is requesting disclosure of Social Security Num bers in accordance with I.C. 4-1-8-1; disclosure is mandatory unde r federal law, and this form will not be processed without it. See 20 C.F. R. § 603.22; 42 C.F.R. § 435.960. DECEDENT INFORMATION   Name Social Security Number * Date of death (mm,dd,yyyy) Address (number and street, city, state, and ZIP code) Comes now _______________________________________________, the affiant herein and pursuant to I.C. 29-1-8-1, being duly swor n, says: (1) The value of the gross probate estate, wherever located (less liens and encumbrances), does not exceed fifty thousand doll ars ($50,000.00). (2) Forty-five (45) days have elap sed since the death of the decedent. (3) No application or petition for the appointment of a personal representative is pending or has been granted in any jurisdict ion. (4) The following person(s) are entitled to the portion of t he decedent’s account listed below. (Please attach additional pages if necessary.) Name Portion of account Address (number and street, city, state, and ZIP code) Name Portion of account Address (number and street, city, state, and ZIP code) (5) I have notified each person identified in this affi davit of my intention to present this affidavit. (6) I am entitled to payment or delivery of the prope rty on behalf of each person identified in this affidavit. Signature Date (mm,dd,yyyy) Printed name Social Security Number * Date of birth (mm,dd,yyyy) Address (number and street, city, state, and ZIP code) CERTIFICATION OF NOTA RY PUBLIC STATE OF ________________________________ SS: COUNTY OF _______________________________ Subscribed and sworn to me, a notary public , in an d for the state a nd county named. Signature of notary public Printed name of notary public County of residence Date commission expires (mm,dd,yyyy)