AFFIDAVIT UNDER CALIFORNIA PROBATE CODE SECTION 13101 (Small Estates Affidavit) The undersigned state(s) as follows: __________________________________________________________ (name of decedent) died on , in the County of ___________________________, State of California and: 1. At least 40 days have elapsed since the death of the decedent, as shown by the attached certified copy of decedent's death certificate. 2. Either of the following, as appropriate: a) No proceeding is now being or has been conducted in California for administration of the decedent's estate. b) The decedent's personal representative has consented in writing to the payment, transfer, or delivery to the affiant or declarant of the property described in the affidavit or declaration. 3. The current gross fair market value of the decedent's real and personal property in California, excluding the property described in the California Probate Code �13050, does not exceed $150,000. 4. An Inventory and Appraisal of the real property in the decedent's estate is attached, or There is no real property in the estate. 5. A description of the property that is to be paid, transferred or delivered to the undersigned under the provisions of California Probate Code �13100 (attach additional sheets if necessary): 6. The successor(s) of the decedent, as defined in Probate Code �13006, is/are: 7. The undersigned is/are successor(s) of the decedent to the decedent's interest in the described property, or The undersigned is/are authorized under California Probate Code �13051 to act on behalf of the successor(s) of the decedent with respect to the decedent's interest in the described property. 8. No other person has a superior right to the interest of the decedent in the described property. 9. The undersigned requests that the described property be paid, delivered or transferred to the undersigned. I/we declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct (attach additional sheets if necessary). DATE PRINTED NAME SIGNATURE 1. Attach a certified copy of death certificate and if there is real property in the decedent's estate attach a completed Inventory and Appraisal (Probate Form DE-160, DE-161). 2. Have this affidavit notarized. PR009 AFFIDAVIT UNDER CALIFORNIA PROBATE CODE � 13101 Rev. 6/10/15 American LegalNet, Inc. www.FormsWorkFlow.com