Fill and Sign the Wisconsin Small Form

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: 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. a person named in the will to act as personal representative. 3. The total gross value of the decedent’s property subject to administration in Wisconsin on the date of decedent’s death was $       (not to exceed $50,000). 4. 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. Explain:       The affiant lacks information to complete this section. 5. 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, 02/18 Transfer by Affidavit ($50,000 and under) §§ 711.03(10) and 867.03, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Transfer by Affidavit ($50,000 and under) 6. I ask that the following property be transferred to me under §867.03(1g), Wis. Stats.: DESCRIPTION OF ASSETS TO BE TRANSFERRED If real estate, list legal description and tax parcel number. (Exception: A person named in the will to act as personal representative may not receive any real property of the decedent.) If personal property (including digital property as defined under § 711.03(10), Wis. Stats.), specifically describe property including name of financial institutions and account numbers, if any. The person who holds the assets may not transfer any money, property, or interest in an asset to a person named in the will to act as personal representative until 30 days after the day on which the affidavit is received. If, during the 30-day period, the person who received the affidavit receives an affidavit for the same decedent from another person, the person who received the affidavit s may not transfer any money due the decedent, the property of the decedent, or any evidence of interest, obligation to, or right of the decedent unless ordered to do so by a court. GROSS VALUE             7. 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, Wis. Stats., and to distribute any balance to those persons designated in the appropriate governing instrument, as defined in § 854.01, Wis. Stats., or if there is no governing instrument, according to the rules of intestate succession under ch. 852, Wis. Stats. 8. 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, 02/18 Transfer by Affidavit ($50,000 and under) §§ 711.03(10) and 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. Except as provided in sub. (1h) and subject to sub, (1j), 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, a person named in the will to act as personal representative, 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, person named in the will to act as personal representative, 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 services provided as a benefit under a long-term care program, as defined in s . 49.496 (1) (bk) , medical assistance under subch. IV of ch. 49 , long-term community support services funded under s. 46.27 (7) , or aid under s. 49.68 , 49.683 , 49.685 , or 49.875. (1h) EXCEPTION FOR REAL PROPERTY. A person named in the will as personal representative may not receive any real property of the decedent by providing an affidavit under sub. (1g) or have any evidence of interest, obligation to, or right of the decedent in any real property of the decedent transferred to the person named in the will as personal representative by providing an affidavit under sub. (1g). (1j) TRANSFERS TO PERSON NAMED TO ACT AS PERSONAL REPRESENTATIVE. A person who receives an affidavit under sub. (1g) from a person named in the will to act as personal representative may not transfer any money due the decedent, the property of the decedent, or any evidence of interest, obligation to, or right of the decedent to the affiant until 30 days after the day on which the affidavit is received. If, during the 30-day period, the person who received the affidavit receives an affidavit under sub. (1g) for the same decedent from another person, the person who received the affidavits may not transfer any money due the decedent, the property of the decedent, or any evidence of interest, obligation to, or right of the decedent under this section unless ordered to do so by a court. Subsection (2) does not apply to a transfer if the transferor did not comply with this subsection. (1m) (a) NOTICE OF AFFIDAVIT. Whenever an heir, trustee, person named in the will to act as personal representative, 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 services provided as a benefit under a long−term care program, as defined in s. 49.496 (1) (bk), medical assistance under subch. IV of ch. 49, long−term community support services funded under s. 46.27 (7), or aid under s. 49.68, 49.683, 49.685, or 49.785, the heir, trustee, person named in the will to act as personal representative, 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, person named in the will to act as personal representative, 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, person named in the will to act as personal representative, 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 services provided as a benefit under a long−term care program, as defined in s. 49.496 (1) (bk), medical assistance under subch. IV of ch. 49, long−term community support services funded under s. 46.27 (7), or aid under s. 49.68, 49.683, 49.685, or 49.785 shall attach to the affidavit the proof of mail delivery of the notice required under par. (a) showing the delivery date. (2) RELEASE OF LIABILITY OF TRANSFEROR. Except as provided in sub. (1j) and subject to sub. (1h), upon the transfer to the heir, trustee, person named in the will to act as personal representative, 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)(a) OBLIGATION OF AFFIANT. By accepting the decedent’s property under this section the heir, trustee, person named in the will to act as personal representative, or person who was guardian of the decedent at the time of the decedent’s death 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, subject to par. (b). An heir, person named in the will to act as personal representative, or person who was guardian of the decedent at the time of the decedent’s death may publish a notice to creditors in the same manner and with the same effect as a trustee under s. 701.0508. This paragraph does not prohibit any appropriate person from requesting administration of the decedent’s estate under s. 856.07 or ch. 865. (b) Property transferred under this section to or by an heir, trustee, person named in the will to act as personal representative, or person who was guardian of the decedent at the time of the decedent’s death is subject to the right of the department of health services to recover under s. 46.27 (7g), 49.496, 49.682, or 49.849 an amount equal to the medical assistance that is recoverable under s. 49.496 (3) (a), an amount equal to aid under s. 49.68, 49.683, 49.685, or 49.785 that is recoverable under s. 49.682 (2) (a) or (am), or an amount equal to long−term community support services under s. 46.27 that is recoverable under s. 46.27 (7g) (c) 1. and that was paid on behalf of the decedent or the decedent’s spouse. Upon request, the heir, trustee, person named in the will to act as personal representative, or person who was guardian of the decedent at the time of the decedent’s death shall provide to the department of health services information about any of the decedent’s property that the heir, trustee, person named in the will to act a personal representative, or person who was guardian of the decedent at the time of the decedent’s death has distributed and information about the persons to whom the property was distributed. (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. [Exception: A person named in the will as personal representative may not accept any real property.] (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 PR-1831, 02/18 Transfer by Affidavit ($50,000 and under) §§ 711.03(10) and 867.03, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Transfer by Affidavit ($50,000 and under) 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, 02/18 Transfer by Affidavit ($50,000 and under) §§ 711.03(10) and 867.03, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2