Fill and Sign the Virginia Small Form

VIRGINIA SMALL E S TA T E ACT A FFIDAVIT Va. Code §64.2-601 Note to the “Person” to whom this Affidavit is delive r ed: Any person having possession of a small asset shall pay or d e liver t h e small ass e t to the d e si g nated successor o f the dece d e n t upon being presented a n affid a vit m ade by all o f the known successors. If you do not understand or have questions regarding your legal responsibilities r e lative to this Affidavit, you sho u ld consult an attorney at law. I/ W E, the“Successor(s)” ___________________________ , after being first duly sworn, depose and state as foll o ws: 1. That ___________________________ , the “Decedent”, died on the ______ day of ___________________________ , 20 ______ . 2. That at the ti m e of d e ath, the Decedent’s estate consisted only of a “S m all Asset”. "Small asset" means any indebtedness owed to or any asset belonging or presently distributable to the decedent, other than real property, having a value, on the date of the decedent's d eath, of no more than $50,000. A small asset i n cludes any b ank account, savings institution account, credit union a ccount, brokerage account, security, deposit, tax refund, overpayment, item of tangible personal property, or an instru m ent evidencing a debt, obligation, stock, or chose in action. A description of the S m all Asset ap p ears b e low: ___________________________ . 3. That the value of Decedent’s entire per s onal p robate estate as of the date of the decedent’s d eath, where v er located, d oes not exceed $50,000.00. 4. That at least 60 days have ela p sed since the Decedent’s death. 5. That no application for the appoint m ent of a p e rsonal representative is pending or has been granted in any jurisdiction. 6. That the Decedent’s will, if any, was duly probated. 7. That the clai m i ng Successor is entitled to pay m ent or delivery of the s m all asset, and the basis upon which such entitle m ent is clai m ed appears below: ___________________________ . 8. The na m e s and addresses of all S u ccessors, to the extent known, are: ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ 9. The na m e of each successor desi g nated to receive pay m ent or delivery of the s m all asset on be h alf of all su c cessors is/a r e: ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ ___________________________ 10. That the Designated Successor shall ha v e a fiduciary duty to safeguard and promptly pay or deliver the s m all asset as req u ired by the laws of the Com m onwealth. WHEREFORE, the undersigned S u ccessor(s) to the S m all Asset of the D ecedent, m ake this Affidavit pursuant to §64.2-601 of the 1950 Code of Virginia, as a m ended. _______________________________ Signature STATE OF ___________________________ , City/County of ___________________________ to-wit: This Virgi n ia S m all Est a te Act A ff i davit was acknowledged, subscribed and sworn to before m e this ______ day of ___________________________ , 20 ______ ,by ___________________________ . My Commission expires: ________________. Notary Registration number: ________________________. NOTARY SEAL _____________________________ NOTARY PUBLIC