Small Estate Affidavit Use this form only if a Will was NOT created when an individual (the "Decedent") died. This form should be submitted to your local Probate County office usually thirty (30) after the death of the Decedent. Enter the Name of the Person who Died First Last Also known as the "Decedent" Residence Which State was the Primary Residence? Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming The State where the Decedent lives most of the time. Location of Death In what County did the Decedent Die? County The County (not country) where the individual (decedent) passed away. In what State did the Decedent Die? Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming Date of Death When did the Decedent die? The date the decedent's death should be the same date as written in the decedent's death certificate. Assets/Debt Are the Assets of the Decedent's estate GREATER or LESS THAN the Decedent's Debt? Are the Assets of the Decedent's estate GREATER or LESS THAN the Decedent's Debt? GreaterLess Than Typically for the heir to receive an inheritance, the decedent's assets should be greater than his/her debt. Heir of Contact Who is the Person filing this Document? First Last Also known as the "Heir of Contact" Mailing Address Street Address Address Line 2 City Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington DCWest VirginiaWisconsinWyoming State ZIP Code Please enter your address. Pending Lawsuits Are there any Pending Lawsuits over the Decedent's Estate? Are there any Pending Lawsuits over the Decedent's Estate? YesNo Select either Yes or No Describe Pending Lawsuit/Litigation State Laws In which State will the Decedent's Property be Distributed? Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWashington D.C.West VirginiaWisconsinWyoming The State selected should be where the decedent permanently resided before their death. What is being claimed under this Small Estate? What is being claimed under this Small Estate? Bank account ($10,000 maximum)Life Insurance ($11,000 maximum)Patient's Care Account ($10,000 maximum)Personal Property ($50,000 maximum)Wages, salary or employee benefits ($10,000 maximum)Unclaimed Property ($11,000 maximum) Only 1 item may be claimed per Small Estate Affidavit in Pennsylvania. If there is more than one (1) item the Affiant will be required to complete another form. If the Affiant is claiming a vehicle then How many Heirs? How many Heirs are there to the Decedent? Select OneOne (1)Two (2)Three (3) Four (4)Five (5)Six (6)Seven (7)Eight (8)Nine (9)Ten (10)Eleven (11)Twelve (12)Thirteen (13) Fourteen (14)Fifteen (15) Select the amount of heirs to the Decedent's estate. Name of Heir #1 First Last How was Heir #1 related to the Decedent? What Property (with value) is Heir #1 Entitled to? Name of Heir #2 First Last How was Heir #2 related to the Decedent? What Property (with value) is Heir #2 Entitled to? Name of Heir #3 First Last How was Heir #3 related to the Decedent? What Property (with value) is Heir #3 Entitled to? Name of Heir #4 First Last How was Heir #4 related to the Decedent? What Property (with value) is Heir #4 Entitled to? Name of Heir #5 First Last How was Heir #5 related to the Decedent? What Property (with value) is Heir #5 Entitled to? Name of Heir #6 First Last How was Heir #6 related to the Decedent? What Property (with value) is Heir #6 Entitled to? Name of Heir #7 First Last How was Heir #7 related to the Decedent? Please enter some text. What Property (with value) is Heir #7 Entitled to? Name of Heir #8 First Last How was Heir #8 related to the Decedent? What Property (with value) is Heir #8 Entitled to? Name of Heir #9 First Last How was Heir #9 related to the Decedent? What Property (with value) is Heir #9 Entitled to? Name of Heir #10 First Last How was Heir #10 related to the Decedent? What Property is Heir #10 Entitled to? Name of Heir #11 First Last How was Heir #11 related to the Decedent? What Property (with value) is Heir #11 Entitled to? Name of Heir #12 First Last Text InputHow was Heir #12 related to the Decedent? What Property (with value) is Heir #12 Entitled to? Name of Heir #13 First Last How was Heir #13 related to the Decedent? What Property (with value) is Heir #13 Entitled to? Name of Heir #14 First Last How was Heir #14 related to the Decedent? What Property (with value) is Heir #14 Entitled to? Name of Heir #15 First Last How was Heir #15 related to the Decedent? What Property (with value) is Heir #15 Entitled to? Additional Assets Are there any Additional Assets or Property? Are there any Additional Assets or Property? YesNo Describe any Additional Assets Who is Entitled to the Above-Mentioned Property? Heir's Debts & Liabilities Does the Decedent’s Estate have any Liabilities or Debts? Does the Decedent’s Estate have any Liabilities or Debts? YesNo List All Liabilities and Debts (Include the amount owed and the Creditor's Information) Signing In which County will this Affidavit be Signed? County Enter the County (not country) where this affidavit will be signed. In which State will this Affidavit be Signed? On what Day will this Affidavit be Signed? Select a date. Death Certificate Do you Agree to Submit a Copy of the Decedent's Death Certificate Along with this Affidavit? Do you Agree to Submit a Copy of the Decedent's Death Certificate Along with this Affidavit? I Agree According to State Law, it is mandatory that you submit a copy of the decedent's death certificate along with this affidavit. Notice to Heirs I Agree to give notice to ALL Heirs within at least 30 days of filing this form I Agree to give notice to ALL Heirs within at least 30 days of filing this form Yes Signature Who will be Present when this Document is Signed? Who will be Present when this Document is Signed? Notary PublicTwo (2) WitnessesNotary Public and Two (2) Witnesses (Recommended) It is recommended that this form be signed in front of a notary public. A notary public can be found at every branch bank or credit union in the United States. Next Save Save and finish later
