STATE OF SOUTH CAROLINA COUNTY OF: _____________________________ IN THE MATTER OF: _________________________________________ (Decedent) The undersigned states as follows: 1. Decedent's Information: ) ) ) ) ) ) ) ) IN THE PROBATE COURT AFFIDAVIT FOR COLLECTION OF PERSONAL PROPERTY PURSUANT TO SMALL ESTATE PROCEEDING CASE NUMBER: ____________________________________ Full Legal Name (include all known names): Date of Birth: Date of Death: Age at date of Death: 2. Decedent was domiciled in this county at date of death: Address: __________________________________________________________________________________________ County: ______________________________________ State: South Carolina. Decedent was not domiciled in South Carolina, but probate property of Decedent was located in this county at date of death at: Address: __________________________________________________________________________________________ County: ______________________________________ State: South Carolina. If the above address is the address of a nursing home, prison, or other residential facility, please give the last address of the Decedent prior to entering the facility: ________________________________________________________________ __________________________________________________________________________________________________ 3. More than thirty (30) days have passed since the Decedent's death. 4. No Application or Petition for the appointment of a Personal Representative is pending or has been granted in any jurisdiction. 5. This affidavit is pursuant to SCPC 62-3-1201. The successor(s) named herein is/are entitled to the payment of any sums of money due and owing to the Decedent, and to the delivery of all probate tangible personal property belonging to the Decedent and in the possession of another, and to the delivery of all instruments evidencing a debt, obligation, stock, or chose in action belonging to the Decedent in the following proportions. Names and addresses of the Decedent's successors (Example: heirs or devisees) are: Name of Successor* Year of Birth Address Relationship Percentage Interest/ Amount See attached sheets for additional successors (check if applicable) (*For this purpose, successors include any person(s) who has/have paid reasonable funeral expenses; attach proof of payment.) Form #420ES (04/2017) 62-3-1201, 62-3-1202 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 6. The value of the entire probate estate wherever located, less liens and encumbrances, does not exceed Twenty-Five Thousand Dollars ($25,000.00) and does not include any interest in real property as indicated below: Bank account Stock Unclaimed Property Motor Vehicle : Mobile Home: Boat/Motor/Trailer: Life Insurance to estate: Other Property (specify): $ $ $ $ $ $ $ $ Bank Name: Company Name: From: VIN: VIN: VIN: Company Name: Type of Account: # of shares: YR/MAKE: YR/MAKE: YR/MAKE: MODEL: MODEL: MODEL: LIENS/ENCUMBRANCES against above assets (attach proof of encumbrance): $ _________________________________ See attached sheet for additional assets/ encumbrances (check if applicable) VERIFICATION The undersigned, being sworn, states: That the facts set forth in the foregoing statements are true to the best of the undersigned's knowledge, information and belief; and the undersigned hereby submits to the Court's jurisdiction in this matter. SWORN to before me this , 20 day of Affiant Signature: Print Name: Address: Notary Public for South Carolina My Commission Expires: Telephone (Work): (Home): (Cell): E-mail: Relationship to Decedent/Estate: ORDER FOR PAYMENT OR DELIVERY It appears from the foregoing affidavit, the original of which is on file with the Probate Court of this county, that payment or delivery of the property described herein should be made as follows: Name of Successor(s) Address Relationship Percentage Interest/ Amount Upon issuance of this Order, this matter is hereby closed. IT IS SO ORDERED this _______ day of ___________________________, 20_________. , Probate Court Judge Note: No person who may act in reliance on this affidavit shall incur any liability to the estate of the Decedent. Form #420ES (04/2017) 62-3-1201, 62-3-1202 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com