AFFIDAVIT UNDER CALIFORNIA PROBATE CODE SECTION 13101 The undersigned state(s) as follows: _________________________________________________ (name of decedent) died on _______________ (date), in the County of ________________, State of California and: 1. At least forty 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 deliver 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 Section 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 Section 13100: _______________________________________________________________________________________ _______________________________________________________________________________________ ________________________ (Attach additional sheets if necessary.) 6. The successor(s) of the decedent, as defined in Probate Code Section 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 Section 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. Date Printed name ________________ __________________________ ________________ __________________________ ________________ __________________________ ________________ __________________________ ________________ __________________________ ________________ __________________________ (Attach an additional sheet if necessary.) 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. _____________________________________________________________________________________ Form Approved for Optional Use Shasta County Superior Court LF-PRB-102 [new July 1, 2012] AFFIDAVIT UNDER CALIFORNIA PROBATE CODE SECTION 13101 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com