Affidavit of Death: Clear Title (Free Template)

STATE OF [STATE]                    )
                                    )  ss.
COUNTY OF [COUNTY]                  )


                          AFFIDAVIT OF DEATH
                  (Identification of Decedent for Title
                  Transfer, Securities Release, and Other
                          Non-Probate Purposes)


    BEFORE ME, the undersigned authority, on this day personally
appeared [Affiant Full Legal Name] (the "Affiant"), who, being
by me first duly sworn upon oath, deposed and stated as follows:


    1.  AFFIANT QUALIFICATIONS. Affiant's full legal name is
        [Affiant Full Legal Name]. Affiant resides at [Affiant
        Street Address, City, State, ZIP]. Affiant is over the
        age of eighteen (18) years and competent to make this
        Affidavit. Affiant has personal knowledge of the facts
        stated herein.

    2.  RELATIONSHIP TO DECEDENT. Affiant's relationship to the
        decedent identified below is [Surviving Spouse / Adult
        Child / Successor Trustee / Personal Representative /
        Joint Tenant / Joint Account Holder / Other:
        ________________].

    3.  DECEDENT IDENTIFICATION. The decedent's full legal name
        was [Decedent Full Legal Name] (the "Decedent"). The
        Decedent was also known as [Aliases used on title,
        account, or vesting records, if any]. The Decedent's
        date of birth was [Date of Birth]. The Decedent's Social
        Security number ended in [Last Four Digits Only]. At the
        time of death the Decedent's residence address was
        [Street Address, City, County, State, ZIP].

    4.  DATE AND PLACE OF DEATH. The Decedent died on [Date of
        Death] in [City, County, State of Death]. A certified
        copy of the Decedent's death certificate, issued by [Name
        of Vital Records Office], is attached hereto as Exhibit
        A and incorporated by reference. The cause of death is
        as stated on the certificate.

    5.  PROPERTY IDENTIFIED BY THIS AFFIDAVIT. This Affidavit
        identifies the Decedent's death for purposes of the
        following property or asset only:

        Option A (Motor Vehicle):
            Vehicle Identification Number (VIN): [17-character VIN]
            Year, Make, Model: [Year] [Make] [Model]
            Title Certificate Number: [Title No.]
            State of Titling: [State]
            Decedent's Ownership Interest: [Sole owner / Joint
                tenant with right of survivorship / Tenant in
                common / Community property]

        Option B (Securities / Brokerage Account):
            Issuer / Custodian: [Name]
            Account or Certificate Number: [Last Four Digits Only]
            Number and Class of Shares: [Number] shares of [Class]
            Decedent's Ownership Interest: [Sole / JTWROS /
                Tenant in common / Beneficiary on TOD designation]

        Option C (Bank or Credit Union Account):
            Institution: [Name]
            Account Number (Last Four Only): [____]
            Account Type: [Checking / Savings / CD / Money Market]
            Decedent's Ownership Interest: [Sole / Joint /
                Payable on Death]

        Option D (Real Property):
            Common Address: [Street, City, County, State, ZIP]
            Legal Description (verbatim from the recorded deed):
                [Lot, Block, Subdivision OR metes and bounds]
            Recording Reference: [Vol. ___, Pg. ___ OR Inst. No.]
            Decedent's Vesting: [Sole / JTWROS / Tenancy by
                Entirety / Tenancy in Common / Community Property]

        Option E (Other):
            [Describe the specific asset, account, policy, or
             interest with sufficient particularity for the
             holder to identify it.]

    6.  AFFIANT'S RIGHT TO RECEIVE OR ACT. Affiant is entitled
        to receive, claim, transfer, or act with respect to the
        property identified in Paragraph 5 by reason of the
        following:

        [Right of survivorship under the JTWROS vesting /
         Payable-on-Death designation / Transfer-on-Death
         designation / Beneficiary designation under the
         account agreement / Statutory non-probate transfer
         under [State Code Section, e.g., a state DMV
         non-probate transfer statute or motor vehicle code
         provision] / Letters Testamentary or Letters of
         Administration issued by [Court, Cause No., Date] /
         Court order entered [Date] in Cause No. ____ / Other:
         _____________].

    7.  ABSENCE OF PROBATE (if applicable). To the best of
        Affiant's knowledge, no proceeding for the administration
        of the Decedent's estate is now pending in any
        jurisdiction. No personal representative of the
        Decedent's estate has been appointed. The asset
        identified in Paragraph 5 passes outside of probate by
        the right described in Paragraph 6. (Delete this
        paragraph if Letters have been issued and the affidavit
        accompanies a Letters certification.)

    8.  KNOWN CREDITORS AND ENCUMBRANCES. Affiant is unaware of
        any unsatisfied lien, levy, security interest, or
        creditor claim against the asset identified in Paragraph
        5 other than: [List any liens or encumbrances by
        recording reference or filing reference; if none, state
        "None"].

    9.  INDEMNIFICATION OF HOLDER. Affiant acknowledges that the
        holder of the asset identified in Paragraph 5 (the
        title issuer, transfer agent, depository institution,
        or recording office) is acting in reliance on this
        Affidavit. Affiant agrees to indemnify and hold the
        holder harmless from any loss caused by the falsity of
        any statement in this Affidavit or by any after-discovered
        claim by a person not identified in this Affidavit. This
        indemnification does not waive any rights of the holder
        under applicable state or federal law and does not limit
        the holder's right to require additional documentation
        if the holder reasonably requests it.

    10. PURPOSE. Affiant executes this Affidavit for the purpose
        of identifying the Decedent's death to [Name of Holder]
        so that the asset identified in Paragraph 5 may be
        retitled, released, or otherwise administered in
        accordance with the right described in Paragraph 6.


    FURTHER AFFIANT SAYETH NAUGHT.


    Executed on this ____ day of ________________, 20____.


                                ____________________________________
                                AFFIANT
                                [Affiant Full Legal Name]
                                [Affiant Street Address]
                                [City, State, ZIP]


PENALTY-OF-PERJURY DECLARATION (Federal Alternative).
Pursuant to 28 U.S.C. Section 1746, Affiant declares under
penalty of perjury under the laws of the United States of
America that the foregoing is true and correct.

    Executed on _______________ at _______________________.


                                ____________________________________
                                AFFIANT


                          JURAT / NOTARY ACKNOWLEDGMENT


STATE OF ______________________ )
                                ) ss.
COUNTY OF _____________________ )

    Sworn to and subscribed before me by [Affiant Full Legal Name]
on this ____ day of ________________, 20____, who is personally
known to me OR produced ______________________________ as
identification, and who being duly sworn deposed that the
statements in the foregoing Affidavit are true and correct of
the Affiant's own personal knowledge.


                                ____________________________________
                                NOTARY PUBLIC, State of __________

                                Printed Name: ______________________

                                My Commission Expires: _____________

                                Notary Seal:




EXHIBITS:
    Exhibit A:  Certified copy of the Decedent's death certificate.
    Exhibit B:  Copy of the vesting deed, title certificate,
                account agreement, or beneficiary designation
                that establishes Affiant's right to receive or
                act under Paragraph 6 (attach the document that
                applies to the asset listed in Paragraph 5).
    Exhibit C:  Affiant's government-issued photo identification
                (if required by the holder).
    Exhibit D:  Any required state-specific transfer form
                completed by Affiant (for motor vehicles, the
                state DMV non-probate transfer form for the
                state of titling; for securities, the
                transfer-agent stock power and medallion-
                signature-guaranteed form, if required).