Fill and Sign the Transfer Affidavit Form 497431339

STATE OF WISCONSIN,       COUNTY Register of deeds recording areaIN THE MATTER OF       Decedent Transfer by Affidavit ($50,000 and under) Note: Use black ink only. Name and return address             parcel identification number UNDER OATH, I STATE THAT: 1. The decedent, with date of birth and date of death , was domiciled in County, State of , with a mailing address of . 2. I am: an heir, having the following relationship to the decedent:       . the person who was guardian of the decedent at the time of the decedent’s death. trustee of a revocable trust created by the decedent. 3. The total gross value of the decedent’s property subject to administration in Wisconsin on the date of death did not exceed $50,000. 4. The total gross value of the decedent’s property subject to administration in Wisconsin at the date of decedent’s death was $       . 5. The decedent: did did not receive Medical Assistance/Medicaid. did did not receive Family Care and/or Partnership benefits (through a Managed Care Organization – MCO/CMO). did did not receive benefits from the Community Options Program (COP). did did not receive benefits from the Wisconsin Chronic Disease Program. was was not patient or inmate of a state or county hospital or institution, or responsible for any person owing an obligation to the state or county. If so, explain:       The affiant lacks information to complete this section. 6. If the decedent was ever married, complete the following: (If more than one spouse, see attached .) Name of spouse ( living or deceased):       . Married to decedent Divorced from decedent at time of decedent’s death. The spouse did did not receive benefits from the Community Options Program (COP). The spouse did did not receive benefits from the Wisconsin Chronic Disease Program. The affiant lacks information to complete this section. PR-1831 , 10/10 Transfer by Affidavit ($50,000 and under) §867.03, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Transfer by Affidavit ($50,000 and under) Page 2 of 2 7. I ask that the following property be transferred to me under §867.03(1g), Wisconsin Statutes: DESCRIPTION OF REAL ESTATE AND/OR PERSONAL PROPERTY TO BE TRANSFERRED (If real estate, list legal description and tax parcel number. If personal property, specifically describe property including name of financial institutions and account numbers, if any.) GROSS VALUE             8. By accepting the decedent’s property under this section, I assume a duty to apply the property transferred for the payment of obligations according to priorities established under § 859.25, Wisconsin Statutes, and to distribute any balance to those persons designated in the appropriate governing instrument, as defined in § 854.01, Wisconsin Statutes, or if there is no governing instrument, according to the rules of intestate succession under ch. 852, Wisconsin Statutes. 9. If a decedent or decedent’s spouse has received any of the benefits that are listed on page 1 of this affidavit or if unknown, a duplicate affidavit must be sent by certified mail with return receipt requested to the Estate Recovery Program for the State of Wisconsin, Department of Health Services prior to submission of this affidavit for recording. The proof of prior mailed notice should accompany the affidavit for recording, with the delivery date on the mail receipt being at least 10 days prior. State of       County of       Subscribed and sworn to before me on       Notary Public/Court Official       Name Printed or Typed My commission/term expires:        Signature       Name Printed or Typed       Address       This document was drafted by:       Print or Type Name Re gister of Deeds Office viewed the certified mail receipt. ONLY if this affidavit describes an interest in or lien on real estate, then a certified copy or duplicate original of this affidavit must be recorded with the register of deeds in each county in Wisconsin where the real estate is located. PR-1831 , 10/10 Transfer by Affidavit ($50,000 and under) §867.03, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 TRANSFER BY AFFIDAVIT (§867.03, Wisconsin Statutes) (1c) DEFINITION. In this section, “guardian” has the meaning given in §54.01(10) or 880.01(3), 2003 statutes. (1g) GENERALLY. When a decedent leaves property subject to administration in this state which does not exceed $50,000 in value, any heir of the decedent, trustee of a revocable trust created by the decedent or person who was guardian of the decedent at the time of the decedent’s death may collect any money due the decedent, receive the property of the decedent and have any evidence of interest, obligation to or right of the decedent transferred to the affiant if the heir, trustee or guardian provides to the person owing the money, having custody of the property or acting as registrar or transfer agent of the evidences of interest, obligation to or right, or, if the property is an interest in or lien on real property, provides to the register of deeds preliminary to the recording required under sub. (2m), proof of prior mailed notice under sub. (1m) if applicable and an affidavit in duplicate showing all of the following: (a) A description of and the value of the property to be transferred. (b) The total value of the decedent’s property subject to administration in this state at the date of decedent’s death. (c) Whether the decedent or the decedent’s spouse ever received the family care benefit under §46.286, medical assistance under subch. IV of ch. 49, long-term community support services funded under §46.27(7) or aid under §§49.68, 49.683 or 49.685. (1m) NOTICE OF AFFIDAVIT. (a) Whenever an heir, trustee or person who was guardian of the decedent at the time of the decedent’s death intends to transfer a decedent’s property by affidavit under sub. (1g) and the decedent or the decedent’s spouse ever received the family care benefit under §46.286, medical assistance under subch. IV of ch. 49, long-term community support services funded under §46.27(7) or aid under §§49.68, 49.683 or 49.685, the heir, trustee or person who was guardian of the decedent at the time of the decedent’s death shall give notice to the department of health services of his or her intent. The notice shall include the information in the affidavit under sub. (1g) and the heir, trustee or person who was guardian of the decedent at the time of the decedent’s death shall give the notice by certified mail, return receipt requested. (b) An heir, trustee or person who was guardian of the decedent at the time of the decedent’s death who files an affidavit under sub. (1g) that states that the decedent or the decedent’s spouse received the family care benefit under §46.286, medical assistance under subch. IV of ch. 49, long-term community support services funded under §46.27(7) or aid under §§49.68, 49.683 or 49.685 shall attach to the affidavit the proof of mail delivery of the notice required under par. (a) showing delivery date that is not less than 10 days before the day on which the heir, trustee or person who was guardian of the decedent at the time of the decedent’s death files the affidavit. (2) RELEASE OF LIABILITY OF TRANSFEROR. Upon the transfer to the heir, trustee or person who was guardian of the decedent at the time of the decedent’s death furnishing the affidavit with an attached proof of mail delivery if required under sub. (1m) (b), the transferor is released to the same extent as if the transfer had been made to the personal representative of the estate of the decedent. (2g) OBLIGATION OF AFFIANT. By accepting the decedent’s property under this section the heir, trustee, or guardian assumes a duty to apply the property transferred for the payment of obligations according to priorities established under § 859.25 and to distribute any balance to those persons designated in the appropriate governing instrument, as defined in § 854.01, of the decedent or if there is no governing instrument, according to the rules of intestate succession under ch. 852. An heir or guardian may publish a notice to creditors in the same manner and with the same effect as a trustee under § 701.065. This subsection does not prohibit any appropriate person from requesting administration of the decedent’s estate under § 856.07 or ch. 865. (2m) RECORDING OF AFFIDAVIT. (a) If an affidavit under sub. (1g) describes an interest in or lien on real property a certified copy or duplicate original of the affidavit shall be recorded in the office of the register of deeds in each county in this state in which the real property is located. (b) For purposes of a transfer under this section of an interest in or lien on real property, the recording of the affidavit copy or duplicate original constitutes the transfer to the affiant under sub. (1g) of the evidence of the interest in or lien on real property. (3) APPLICABILITY. This section is additional to §109.03(3) for payment of decedent’s wages by an employer directly to the decedent’s dependents. Address for: Department of Health Services Estate Recovery Program P. O. Box 309 Madison, WI 53701-0309 NOTE: If you are providing a copy of this affidavit to the Estate Recovery Program or a financial institution, include decedent’s social security number on a separate document. PR-1831 , 10/10 Transfer by Affidavit ($50,000 and under) §867.03, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material.