IN THE CIRCUIT COURT OF JEFFERSON COUNTY, MISSOURI AT IN THE ESTATE OF ESTATE NUMBER , Deceased AFFIDAVIT TO ESTABLISH TITLE OF DISTRIBUTEE TO PROPERTY IN ESTATE OF LESS THAN $40,000.00 The undersigned, * (a person designated as personal representative under the will of the decedent presented for probate within the limitation periods specified in Section 473.050, RSMo.) * (a distributee entitled to receive property of the decedent), being first duly sworn, states: Decedent resided at and died on *(Decedent left a will that was presented for probate within the limitation periods specified in Section 473.050, RSMo. which was duly admitted to probate by this court on ). *(No will has been presented for probate). All unpaid debts, claims or demands against the decedent or the decedent's estate and all estate taxes due, if any, on the property transfers involved, have been or will be paid, except that any liability by the affiant for the payment of unpaid claims shall be limited to the value of the property received. Attached hereto as Appendix A is an itemized description and valuation of all the property of said decedent, together with the names and addresses of the persons having possession of the same (including registrars or transfer agent of all corporate shares and bonds). Attached hereto as Appendix B are the names, addresses and relationship to the decedent of the persons entitled to and who will receive the specific items of property remaining after payment of claims and debts of the decedent. Included in the affidavit are the facts establishing their right to such specific items of property described in Appendix A attached hereto. The value of the entire estate, less liens and encumbrances, does not exceed the amount of forty thousand dollars. Thirty days have elapsed since the death of the decedent and no application for letters estamentary or for administration or for refusal of letters under Section 473.090, RSMo. is pending or has been granted. (A bond in the amount of $ approved by the court). with corporate surety has been filed with and AFFIANT: ADDRESS: TELEPHONE: ( ) Subscribed and sworn to before me on by (affiant's name) Notary commission expires Notary Public Division Clerk Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com The undersigned distributees- hereby waive bond. Subscribed and sworn to before me on by (distributee's name) Notary commission expires Division Clerk Notary Public ATTORNEY FOR AFFIANT: MO BAR No ADDRESS: TELEPHONE: ( FAX NUMBER: ( ) ) E-MAIL ADDRESS: Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX A REALPROPERTY (give legal description and street address, valuation, less liens and encumbrances) PERSONS HAVING POSSESSION (give name and address) $ PERSONAL PROPERTY (value less liens and encumbrances) Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com ESTATE NO. APPENDIX B NAME ADDRESS RELATIONSHIP Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com