Fill and Sign the North Carolina Small Estate Affidavit for Collection of Personal Property of Decedent Intestate Testate Form

Date Of Will The decedent died on or after 10/1/09 and the val ue of all personal property owned by the decedent less liens and emcumbrances thereon, and less the spousal al lowance under G.S. 30-15, I am the survivi ng spouse and sole heir devisee of the decedent, the decedent died on or after 10/1/09, and the value of all personal property, less liens and encumbrance s thereon, and less the spousal allowance under G.S. 30-15, does The decedent died intestate. testate. At least thirty (30) days have passed since the date of the dec edent's death. No application or petition for appointment of a personal representative is pending or has been granted in any jurisdiction. After diligent inquiry, I have determi ned that the persons listed below are all the persons entitled to share in the dec edent's estate. ( If there is a c ourt-appointed guardian for any such perso n(s), list the guardian's name and address on an attachment.) (Check if decedent died testate.) Decedent's will dated as shown above has been pro bated in each county in which is located any real property owned by t he decedent as of the da te of death; and a certified copy of the decedent's will is attached to this Affidavit. I, t he undersigned affiant, being first duly sworn, say that: Original - File Copy - Fiduciary Copy - Clerk Mails Copy To Each Person Listed In Item No. 7 (Over) (a) (b) I am an heir. an executor named in the will. a devisee named in the will. the p ublic administrator a creditor of t he decedent. I am not disq ualified under G.S. 28A-4-2. 1. 3. 4. 2. 6. 5. 7. F ile No. STATE OF NORTH CAROLINA IN THE MA TTER OF THE ESTATE OF: Name, Street Address, City, State And Zip Code Of Decedent (TYPE OR PRINT I N BLACK INK) Telephone No. Social Security No. (Last F our Digits) Date Of Death Telephone No. Name, Street Address, PO Box, City, State And Zip Code Of Affiant 1 Legal Residence (County, State) Name, Street Address, PO Box, City, State And Zip Code Of Attorney County Of Domicile At Time Of Death Place Of Death (If Different From County Of Domic ile) Telephone No. Legal Residence (County, State) Attorney Bar No. Name, Street Address, PO Box, City, State And Zip Code Of Affiant 2 NAME AGE RELATIONSHIP MAILING ADDRESS AOC-E-203B, Rev . 5/12 © 2012 Administrative O ffice of the Courts In The General Court Of Justice Superior Court DivisionBefore The Clerk County AFFIDAVIT FOR COLLEC TION OF PERSO NAL PROPERTY OF DECEDENT G.S. 28A-25-1; 28A-25-1.1 INTESTATE T ESTATE does not exceed $20,000. not exceed $30,000. (For Decedents Dying On Or After Jan. 1, 2012) Joint accounts without right of survivorship (List bank, etc., each account no., balance and joint owners.) SEAL Cash and undeposited checks on hand........................................................................................................\ . Household furnishings....................................................................................................................................\ Farm products, livestock, equipm ent and tools..............................................................................................\ Vehicles (include or attach descriptions) Interest in partnership or sole proprietor businesses...................................................................................\ ... Insurance, Retirement Plan, I.R.A., etc., payable to Estate........................................................................\ ... Notes, judgments, and other debts due decedent............. .............................................................................\ Miscellaneous personal property....................................................................................................................\ Real estate willed to the Estate.................................................................... Estimated annual income of Estate................................................................................................................\ Stocks/bonds/securities in sole name of dec edent or jointly owned without right of survivorship............................................................................................. Accounts in sole name of decedent (List bank, etc., each account no. and balance.) There is is not entireties real estate owned by decedent and spouse .......................................... There are are not Insurance, Retirement Plan, I.R.A., acc ounts, etc., payable to named beneficiaries...............................................................\ ....................................................................................\ . Joint accounts with right of survivorship (List bank, etc., each account no., balance and joint owners.) Stocks/bonds/securities registered in beneficiary form and immediately transferred on death or jointly owned with right of survivorship .......................................... ...........................................................................\ Other personal property recov erable G.S. 28A-15-10).................................................................................\ .. Real estate owned by decedent and not listed elsewhere (attach description) ................................................. (Base bond on this amount, if applicable.) TOTAL PART I. TOTAL PART II. Signature Deputy CSC Assistant CSC Clerk Of Superior Court CERTIFICATION I certify that the foregoing is a true and accurate copy as taken from and compared with the original on record in this office. Date SEAL NOTE: This Affidavit for Co llection of Personal Property of Decedent authorizes the named co llector by affidavit to receive and administer ALL of the personal property belonging to the named decedent pursuant to G.S. Chapter 28A, Article 25. Date SEAL Notary Deputy CSC A ssistant CSC Clerk Of Superior Court SWORN/AFFIRMED AND SUBSCRIB ED TO BEFORE ME Signature Of Person Authorized To Administer Oaths Date Commission Expires County Where Notarized Signature Of Co llector By Affidavit 1 Name (Type Or Print) % Owned By Dec. 3. 2. 3. 4. 1. 1. 2. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. PART II. PROPERTY WHICH CAN BE ADDED TO ESTATE IF NEEDED TO PAY CLAIMS PARTIII.OTH ER PR OPERTY 1. 2. $ $ $ PRELIMINARY INVENTORY (Give values as of date of decedent's death. Continue on separate attachment if necessary.) PARTI. PROPERTY OF THE ESTATE Est. Market Value % Owned By Dec. % Owned By Dec. % Owned By Dec. % Owned By Dec. $ $ Signature Of Co llector By Affidavit 2 Name (Type Or Print) Notary Deputy CSC Assistant CSC Clerk Of Superior Court DateSWORN/AFFIRMED AND SUBSCRIB ED TO BEFORE ME Signature Of Person Authorized To Administer Oaths Date Commission Expires County Where Notarized AOC-E-203B, Side Two, Rev. 5/12 © 2012 Administrative O ffice of the Courts