Fillable Printable Small Estate Affidavit Under Pennsylvania Statutes

Small Estate Affidavit Under Pennsylvania Statutes

SMALL ESTATE AFFIDAVIT UNDER PENNSYLVANIA STATUTES 20 § 3101(d)

State of ____________________________

County of ____________________________

I, _______________________________________________________, the (affiant) state:

1. __________________________________ (name of decedent) died on ____________ (date), and was a

resident of _______________(county), State of Pennsylvania at the time of death.

2. The total amount of proceeds payable does not exceed $11,000.

3. Sixty (60) days have elapsed since the death of the insured.

4. I understand that payment cannot be made under this affidavit if a written claim for the money has been

received from a personal representative of the decedent’s estate.

5. I am entitled to payment or delivery of the property as heir of the decedent because there is no other heir

that has preference or any heirs that have preference have released their benefits to me. (Pennsylvania

law gives preference in the following order: spouse, child, father or mother, or sister or brother.)

6. All heirs of the decedent are listed below (spouse, child, father, mother, sister, and brother).

Name Age Relationship to Decedent

Executed on __________________(date), at ____________________(city) ________(state).

__________________________________________

(signature of affiant)

__________________________________________

(relationship to decedent)

Sworn and subscribed to before me this _______day of ___________(date).

_______________________________________________

Notary Public, State of ____________________________