J DF 999 SC R 6 /1 9 COLLECTION OF PERSONAL PROPERTY BY AFFIDAVIT PURUSANT TO 247 15 - 12 - 1201, C.R.S. Page 1 of 2 STATE OF COLORADO COUNTY OF COLLECTION OF PERSONAL PROPERTY BY AFFIDAVIT PURSUANT TO 247 15 - 12 - 1201 , C.R.S. NOTICE If a person or entity holding property of a decedent refuses to honor this a ffidavit without reasonable cause, such person or entity will be liable for all costs, including reasonable attorney fees and costs, incurred by or on behalf of the persons entitled so such property ( 247 15 - 12 - 1202(3), C. R.S.) The person or entity paying, delivering, transferring, or issuing personal property pursuant to this affidavit is discharged and released to the same extent as if he , she , or it dealt with a personal representative of the Decedent. ( 247 15 - 12 - 1202(1 ) , C.R.S.). 1. I, , the a ffiant, am either a successor of the d ecedent or a person acting on behalf of one or more of the successors of the decedent, and I am 18 years of age or older. 2. At least 10 days have elapsed since the death of ( d ecedent ) . 3. The total fair market value of all property owned by the d ecedent and subject to disposition by w ill or intestate succession at the time of the d encumbrances, does not exceed , fo r year of death ( Y.O.D. ) : Y.O.D. 2019 is $68,000; 2017 and 2018 is $66,000; Y.O.D. 2016, 2015 , and 2014 is $64,000; and Y.O.D . 201 3 is $ 63,000 . 4. This affidavit is not valid for the transfer of real estate . To transfer personal property that affects real estate see 247 15 - 12 - 1201(3.5) , C.R.S. 5. N o a pplication or p etition for the appointment of a personal representative is pending or has been granted in any jurisdiction. 6. The s uccessor(s), listed below, is/are entitled to any personal property belonging to the d ecedent, including but not limited to funds on deposit at , or any contents of a safe deposit box at , any financial institution ; tangible personal property ; or instrument evidencing a debt, obligation, stock, chose in action (right to bring a legal action), or stock brand. The amount, proportion or percentage that each Successor is entitled to is as follows (see Instructions): Name of Successor Description of Property Am ount American LegalNet, Inc. www.FormsWorkFlow.com J DF 999 SC R 6 /1 9 COLLECTION OF PERSONAL PROPERTY BY AFFIDAVIT PURUSANT TO 247 15 - 12 - 1201, C.R.S. Page 2 of 2 7. The property must be paid or delivered as described in the following table and then the property will be distributed to successors in accordance with paragraph 6 above (see Instructions): Name of Successor or Person collecting on behalf of one or more Successors Description of Property Amount 8. Any person collecting property on behalf of one or more successors will be deemed an agent of such successor with all the duties of an agent under Colorado law. 9. I understand that any person who receives property pursuant to this affidavit is answerable and accountable to any subsequently appointed personal representative of the estate or any other person having a superior right to the estate. VERIFICATION AND ACKNOWLEDGMENT I, (name) swear/affirm under oath, that I have read the foregoing COLLECTION OF PERSONAL PROPERTY BY AFFIDAVIT P URSUANT TO 247 15 - 12 - 1201, C.R.S. and that the statements set forth therein are true and correct to the best of my knowledge. Printed name Signature Date Subscribed and affirmed, or sworn to before me in the County of , State of , this day of , 20 . My Commission Expires: Notary Public/Clerk American LegalNet, Inc. www.FormsWorkFlow.com