STATE OF NEBRASKA COUNTY OF ______________ (county in which the document will be signed) ) ) ) Affidavit for Transfer of Personal Property without Probate I, ________________________, under penalty of perjury under Nebraska Revised Statute §28-915, (your name) swear or affirm the following to be true and material: 1. 2. 3. thirty days have passed since ___________________'s death; (deceased's name) a certified or authenticated copy of the deceased's death certificate is attached to this affidavit; the value of the entire estate of the deceased, ___________________, less liens and (deceased's name) encumbrances (claims against or on the property), is $50,000.00 or less; 4. 5. there is no Personal Representative, application for Personal Representative, or petition for Personal Representative; and I am entitled to payment and delivery of all property held by others in the sole name of the deceased, _______________________, pursuant to Nebraska Probate Code §30-24,125 and because of my (deceased's name) relationship as ____________________________________ to the deceased. As provided under Nebraska Probate Code §30-24,126, the person releasing personal property or the evidence of property based upon this affidavit is discharged and released just as if that person dealt with a Personal Representative of the deceased. The person releasing the property is not required to see to the application of the personal property or evidence of that application or to inquire into the truth of any statement in this affidavit. A transfer agent of any security shall change the registered ownership on the books of a corporation from the decedent to the successor or successors upon the presentation of the affidavit. _______________________________ Date _______________________________ Address (line 1) _______________________________ Address (line 2) NOTARY State of Nebraska, County of _________________ This document was acknowledged before me on the ______ day of ____________, 20_____, (day) (month) (year) __________________________________________ Signature (do NOT sign UNTIL A NOTARY IS PRESENT AND WITNESSES YOU SIGNING) by ___________________________ (Affiant's name) _____________________________ (Seal, if any) Signature of Notary My commission expires: ___________________ Page 1 of 1 Affidavit for Transfer of Personal Property without Probate CC 15:40 New 07/14 Pro Se Committee Neb. Rev. Stat. §30-24,125 American LegalNet, Inc. www.FormsWorkFlow.com