Small Estate Affidavit

I, [____________] ("Affiant"), being duly sworn, depose and state under penalty of perjury that [____________] ("Decedent") died on [____________] in [____________] County, State of [_____________], and that the gross fair market value of all personal property comprising the Decedent's estate subject to this Affidavit does not exceed the statutory threshold for small estates in the State of [_____________], currently [$__________] as set forth in [applicable statute, e.g., UPC § 3-1201 or state equivalent], exclusive of liens, encumbrances, and property passing outside of probate by beneficiary designation, joint tenancy, or trust.

The property subject to this Affidavit is specifically identified as follows (the "Property"): [description of personal property, financial accounts, vehicle(s), or other assets, include account numbers, vehicle identification numbers, or other identifying information]. Affiant represents that the aggregate fair market value of all personal property of the Decedent, wherever located, as of the date of death, does not exceed the applicable statutory limit, and that no petition for the appointment of a personal representative is pending or has been granted in any jurisdiction.

Affiant is entitled to the Property described herein by reason of the following: [check all that apply] (a) Affiant is the surviving spouse of the Decedent and the Property constitutes community property or property subject to spousal rights of succession under the laws of the State of [_____________]; (b) Affiant is an heir of the Decedent as defined by the intestate succession laws of the State of [_____________], specifically as the Decedent's [relationship: ____________]; (c) Affiant is a beneficiary named in the Decedent's will dated [____________], a true copy of which is attached hereto as Exhibit A; or (d) Affiant is otherwise legally entitled to the Property by reason of [____________].

Affiant further declares that: (a) no other person has a superior right to the Property, and to the best of Affiant's knowledge no other person claims an interest adverse to Affiant's entitlement; (b) the Decedent's will, if any, has not been admitted to probate in any jurisdiction, or if admitted, the Property described herein is not subject to the probate estate; (c) no petition for appointment of a personal representative of the Decedent's estate is pending or has been granted in any jurisdiction; (d) at least [thirty (30) / forty-five (45)] days have elapsed since the Decedent's death, as required by applicable state law; and (e) Affiant is not aware of any outstanding creditor claims or liens against the Property that would reduce its net value below the statutory threshold.

The Property to be transferred pursuant to this Affidavit consists of the following specific items: [list each item separately, including (a) financial accounts, institution name, account number, approximate balance; (b) vehicles, year, make, model, VIN, title number; (c) personal property, description and estimated value; (d) other personal property, description and estimated value]. The total estimated fair market value of all Property listed herein is approximately [$__________], which is within the applicable statutory small estate limit.

Affiant requests that each holder of the Property described herein transfer and deliver the Property, or the Affiant's proportionate share thereof, to Affiant forthwith. If there is more than one successor entitled to the Decedent's estate, the Property shall be distributed as follows: [name of each successor, relationship, and proportionate share, e.g., per the Decedent's will / per intestate succession law of the State of [_____________] / as agreed among successors per written agreement attached as Exhibit B]. Each successor's share shall be calculated as follows: [____________].

Affiant, individually and on behalf of all other successors identified herein, hereby agrees to indemnify, defend, and hold harmless each and every person and institution that transfers property to Affiant in reliance on this Affidavit from and against any and all claims, demands, losses, damages, costs, and expenses, including reasonable attorneys' fees, arising out of or relating to: (a) any misrepresentation or false statement contained in this Affidavit; (b) any failure to disclose the existence of other successors entitled to the Property; (c) any claims by creditors or other parties with superior rights to the Property; or (d) any failure of Affiant to properly distribute the Property to other entitled successors.

Affiant acknowledges that this Affidavit is executed under penalty of perjury pursuant to the laws of the State of [_____________] and, where applicable, the laws of the United States. Affiant understands that knowingly making false statements in this Affidavit may subject Affiant to criminal prosecution for perjury or false swearing, civil liability to parties damaged by such false statements, and liability for the return of any property wrongfully obtained. Affiant further understands that if this Affidavit is found to contain material misrepresentations, any holder who transferred property in good-faith reliance hereon shall be fully indemnified by Affiant.