Fill and Sign the Nevada Property 497320854 Form

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Document Code __________________ (Your name) __________________ (Address) __________________ __________________ (Telephone) __________________ In Proper Person DISTRICT COURT ____________ COUNTY, NEVADA In the Matter of the ) Estate of: _______________________ ) CASE NO.: _______________ DEPT. NO.: _______________ SMALL ESTATE AFFIDAVIT Collection of Personal Property State of Nevada County of _______________________________ I, _______________________________ , upon being duly sworn, state on my oath that: 1. My post office address is: _______________________________ . 2. My residence address is: _______________________________ . 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 3. I am a legal successor to the decedent, _______________________________ , who resided at _______________________________ Nevada at the time of death, and am entitled by law to succeed to the property claimed. 4. I am entitled to be named as a successor to the decedent due to my relationship to the decedent, or I have a claim to the personal property of the decedent, namely: _______________________________ 5. The decedent passed from this life on the __________ day of __________________________ , 20 __________ . 6. The gross value of the decedent's property in this state, except amounts due to the decedent for services in the Armed Forces of the United States or the value of any motor vehicles registered to the decedent, does not exceed the applicable amount, and that the property does not include any real property nor interest therein, nor mortgage or lien thereon. 7. At least forty (40) days have elapsed since the death of the decedent, as shown in a certified copy of the certificate of death of the decedent attached to this affidavit. 8. That no petition for the appointment of a personal representative is pending or has been granted in any jurisdiction. 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 9. That all debts of the decedent, including funeral and burial expenses, and money owed to the department of human resources as a result of the payment of benefits for Medicaid, have been paid or provided for. 10. The following is a description of personal property of the decedent known to the affiant and the portion claimed hereby: __________________________ . 11. The affiant has given written notice, by personal service or by certified mail, identifying the affiant's claim and describing the property claimed, to every person whose right to succeed to the decedent's property is equal or superior to that of the affiant, and that at least 14 days have elapsed since the notice was served or mailed; 12. The affiant is personally entitled, or the Department of Human Resources is entitled, to full payment or delivery of the property claimed or is entitled to payment or delivery on behalf of and with the written authority of all other successors who have an interest in the property. 13. The affiant has no knowledge of any existing claims for personal injury or tort damages against the decedent. 14. The affiant hereby acknowledges and understands that the filing of a false affidavit constitutes a felony in this state. 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 THE FOREGOING STATEMENT IS MADE UNDER THE PENALTIES OF PERJURY. ________________________________________ Signature of Affiant ACKNOWLEDGMENT STATE OF NEVADA ) ) ss: COUNTY OF _________ ) On this _______ day of ____________ , ______ , before me, the undersigned Notary Public in and for the said County and State, personally appeared ______________ , known to me to be the person described in and who executed the foregoing Small Estate Affidavit, and who acknowledged to me that he did so freely and voluntarily and for the uses and purposes therein mentioned. WITNESS my hand and official seal. ___________________________________ NOTARY PUBLIC 4