11/30/2016 Form 23 Affidavit for Collection of Small Estate by Distributee NOTE: Form revised to conform to current statutory language raising small estate from $50,000 to $100,000 per the direction of the Arkansas Supreme Court Committee on Civil Practice [51107]. Form 23. [Caption] AFFIDAVIT FOR COLLECTION OF SMALL ESTATE BY DISTRIBUTEE ________, ________ and ________, for the purpose of dispensing with administration of this estate, deceased, state on oath: 1. The decedent ___________, aged ___, who resided at ________ in __________ County, Arkansas, died at ________ on or about [date]. No petition for the appointment of a personal representative for the decedent's estate is pending or has been granted. 2. More than fortyfive (45) days have elapsed since decedent's death. 3. The value, less encumbrances, of all property owned by the decedent at the time of death, excluding the homestead of and statutory allowances for the benefit of the surviving spouse or minor children, if any, of the decedent, does not exceed one hundred thousand dollars ($100,000). 4. There are no unpaid claims or demands against the decedent or the decedent's estate, and the Department of Human Services furnished no federal or state benefits to the decedent (or, that if such benefits have been furnished, the Department of Human Services has been reimbursed in accordance with state and federal laws and regulations). 5. An itemized description and valuation of the decedent's personal property a legal description and valuation of the decedent's real property, including homestead, if any and the names and addresses of persons having possession thereof orresiding on any of the decedent's real property, are: Description of Property, and Extent Valuation Less and Details of Encumbrances, if Any Encumbrances In Possession of ___________________________________ ______________ ________________ ___________________________________ ______________ ________________ 6. The names, ages, relationships to the decedent and residence addresses of the persons entitled to receive the property of the decedent as surviving spouse, heirs or devisees of decedent's will are: Name Age Relationship Residence Address https://courts.arkansas.gov/system/files/form23.html American LegalNet, Inc. www.FormsWorkFlow.com 1/2 11/30/2016 Form 23 Affidavit for Collection of Small Estate by Distributee __________________ ____ ____________ __________________ __________________ ____ ____________ __________________ THEREFORE, the distributee[s] of this estate shall be entitled to distribution of the property identified above, without the necessity of an order of the court or other proceeding, upon furnishing a copy of this Affidavit, certified by the clerk, to any person owing any money, having custody of any property, or acting as registrar or transfer agent of any evidence of interest, indebtedness, property or right of the decedent. Date: ___________, ____. ________________________________ [Affiant] ________________________________ [Affiant] ________________________________ [Affiant] [Affidavit] CERTIFICATE OF CLERK The undersigned Clerk of the Probate Court of ___________ County, Arkansas, certifies that this is a true copy of an affidavit filed in this court on [date], that the affidavit remains on file and that no petition for the appointment of a personal representative of this estate has been filed in this court. Date: __________, ____. __________________________, Clerk. By: ________________, Deputy Clerk. (Seal) Reporter's Notes to Form 23: See Ark. Code Ann. � 2841101. The language in parentheses in Paragraph 4 should be substituted for the language immediately preceding it if the Department of Human Services furnished benefits to the decedent. An affidavit by the distributee is required by Ark. Code Ann. � 2841101(a)(4). If an estate collected pursuant to this affidavit contains real property, the distributee, to allow for presentation of claims against the estate, may publish a notice promptly after the affidavit has been filed. Ark. Code Ann. � 2841101(b)(2). https://courts.arkansas.gov/system/files/form23.html American LegalNet, Inc. www.FormsWorkFlow.com 2/2