Fill and Sign the Pa Small Estate Form

© 2016 - U.S. Legal Forms, Inc. PENNSYLVANIA SMALL ESTATE AFFIDAVIT FOR INSURANCE PROCEEDS ONLY [Pa. Statutes 20§3101(d) ] Control Number: PA-ET10 I. TIPS ON COMPLETING THE FORMSThe form(s) in this packet may contain “form fields” created using Microsoft Word or Adobe Acrobat (“.pdf” format). “Form fields” facilitate completion of the forms using your computer. They do not limit your ability to print the form “in blank” and complete with a typewriter or by hand. It is also helpful to be able to see the location of the form fields. Go to the View menu, click on Toolbars, and then select Forms. This will open the Forms toolbar. Look for the button on the Forms toolbar that resembles a shaded letter “a”. Click this button and the form fields will be visible. By clicking on the appropriate form field, you will be able to enter the needed information. In some instances, the form field and the line will disappear after information is entered. In other cases, it will not. 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Small Estate AffidavitPage 1 of 1 SMALL ESTATE AFFIDAVIT FOR INSURANCE PROCEEDS UNDER PENNSYLVANIA STATUTES 20 § 3101 (d) NOT to be used for Settlement of Small Estates under 20 Pa.C.S.A. §3102 (Original Death Certificate Must Accompany this Form) Decedent: ____________________________ Social Security Number: ____________________________ Case or File Number: ____________________________ Commonwealth of Pennsylvania, County of ____________________________ 1. ____________________________, states that ____________________________ , (name of affiant) (name of decedent) died on ____________________________ , and was a resident of ______________________, (date) State of Pennsylvania at the time of death. 2. The total amount of proceeds payable by ____________________________ (name of company) does not exceed $11,000. 3. Sixty (60) days have elapsed since the death of the insured. 4. I understand the payment cannot be made under this affidavit if a written claim for the money has been received from a personal representative of the decedent’s estate. 5. I’m entitled to payment or delivery of the property as heir of the decedent because there is no other heir that has preference or any heirs that have preference have released their benefits to me. (Pennsylvania law gives preference in the following order: spouse, child, father or mother, or sister or brother.) 6. All heirs of the decedent are listed below (spouse, child, father, mother, sister, and brother). Name Relationship to Decedent Residence ____________________________ ____________ ____________________________ ____________________________ ____________ ____________________________ ____________________________ ____________ ____________________________ ____________________________ ____________ ____________________________ ____________________________ ____________ ____________________________ ____________________________ ____________ ____________________________ 7. Your Petitioner avers there are NO KNOWN PROBATABLE ASSETS that would require an estate proceeding. Therefore, NO ESTATE WILL BE RAISED, AND LETTERS ARE NOT NECESSARY Small Estate AffidavitPage 2 of 1 8. Except as follows, Decedent did not marry, was not divorced, and did not have a child born or adopted after execution of any testamentary writings whether or not offered for probate; was not the victim of a killing, was never adjudicated an incapacitated person, and was not a party to a pending divorce proceeding at the time of death wherein grounds for divorce had been established as defined in 23 PA C.S. section 3323(g): ____________________________. Date: ____________________________ Signature of Affiant ____________________________ Print or Type Name ____________________________ Relationship to Decedent Sworn to and subscribed before me this _________ day of ____________________ , 20_________ . Notary Public BE IT REMEMBERED, that as of this _________ day of ____________________ , 20_________, there has been NO ESTATE RAISED FOR THIS DECEDENT AND NO LETTERS HAVE BEEN ISSUED BY THIS COURT. ___________________________________ ____________________ Register of Wills & Clerk of Orphans’ Court