CIRCUIT COURT OF CLAY COUNTY, MISSOURI PROBATE DIVISION Estate No.CV2 IN THE ESTATE OF , Deceased. AFFIDAVIT TO ESTABLISH TITLE OF DISTRIBUTEE TO PROPERTY IN ESTATE HAVING LESS THAN $40,000.00 The undersigned, a person having knowledge of the facts hereinafter stated, being first duly sworn, states: Decedent’s date of birth was ____________________, and died on ____________________. Decedent resided at ___________________________________________________. *(Decedent left a Will, which was duly admitted, to Probate by this Court on ___________________.) *(No Will has been presented for Probate.) Attached hereto as Appendix C listing all debts, unpaid taxes, claims or demands against the decedent or his estate on the property, transfers involved, have been or will be paid except that any liability by the Affiant’s 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 of the property of said decedent, together with the names and addresses of the persons having possession of the same (including registrars or transfer agents 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 property, and who are entitled at the present time to take a defeasible interest in said property, and the facts establishing their right to the real and personal property described in Appendix A attached hereto. The value of the entire estate, less debits, 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 or for administration or for refusal of letters under Section 473.090 RSMo, is pending or has been granted. *strike if inapplicable (A bond in the amount of $_________________________, with corporate surety has been filed with and approved by the Court.) Form 556-D Revised 5/1/2007 Page 1 of 5 American LegalNet, Inc. www.FormsWorkflow.com AFFIANT:______________________________________ ( SIGNATURE ) ADDRESS_____________________________________ TELEPHONE___________________________________ Subscribed and sworn to before me on________________________________________________________, Notary commission expires ______________________________________ _________________________________________ Notary Public Division Clerk The undersigned distributees hereby waive bond. Subscribed and sworn to before me on________________________________________________________ Notary commission expires Notary Public ATTORNEY FOR AFFIANT: Division Clerk Bar #: _________ ADDRESS ZIP TELEPHONE: Form 556-D Revised 5/1/2007 Page 2 of 5 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX A REAL PROPERTY (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) Form 556-D Revised 5/1/2007 Page 3 of 5 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX B NAME Heirs or Legatee’s Include Spouse, Children, (court will need to know if there is/is not a surviving spouse or minor children) Parents, Lineal Descendants, Guardians/Conservators, Trustees RELATIONSHIP BIRTH DATE ADDRESS (thru whom) (if under 18) Complete IF PREDECEASED, PLEASE INDICATE DISTRIBUTEE’S NAME RELATIONSHIP COMPLETE ADDRESS The facts establishing the foregoing named persons’ right to decedent’s real and personal property as prescribed by Section 473.097 RSMo are as follows: Form 556-D Revised 5/1/2007 Page 4 of 5 American LegalNet, Inc. www.FormsWorkflow.com APPENDIX C To Whom Owed Form 556-D Revised 5/1/2007 Address $ Amount Page 5 of 5 American LegalNet, Inc. www.FormsWorkflow.com