1 2 3 4 AFFT Name Name (Attorneys Include Bar No. & Firm) ______________________________________ ______________________________________ Address ______________________________________ City, State, Zip ______________________________________ Telephone ______________________________________ In Proper Person or Attorney for 5 AFFIDAVIT OF ENTITLEMENT TO ESTATE DOES NOT EXCEED $20,000 PURSUANT TO NRS 146.080 6 7 STATE 8 STATE OF 9 COUNTY OF COUNTY 10 ss: Affiant 11 12 ) ) ) , being first duly sworn, upon oath says: That he/she is a person who has a right to succeed to the property of the 13 decedent, or a person who is the sole beneficiary under the last will and testament of 14 the decedent, 15 Name County , who died in the County of State of Nevada, leaving an estate in the County of County , , State of 16 17 Nevada, which is not real property nor interest therein, nor a lien thereon, of a gross 18 value of less than $20,000, consisting of the following: 19 ______________________________________________________________________ List Property 20 ______________________________________________________________________ 21 ______________________________________________________________________ 22 23 24 (Set forth bank account, T/CD, stock certificate, or whatever the asset may be and the portion claimed.) That he/she has the right, pursuant to the provisions of NRS 146.080, to succeed 25 26 27 28 to said property of said decedent, and to have any evidence of interest, indebtedness or right transferred to him or her by _______________________________. County That at least 40 days have elapsed since the date of death of decedent. Afft_of_Entitlement_to Estate.doc 8/11/2005 American LegalNet, Inc. www.USCourtForms.com 1 2 3 4 That no application or petition for the appointment of a personal representative is pending or has been granted in any jurisdiction. That all debts of the decedent, including funeral and burial expenses and money 5 owed to the department of human resources as a result of payment of benefits for 6 Medicaid, have been paid or provided for. 7 8 That affiant has given written notice, by personal service or by certified mail, identifying his claim and describing the property claimed, to every person whose right to 9 10 11 succeed to the decedent’s property is equal or superior to that of affiant, and that at least 14 days have elapsed since the notice was served or mailed. 12 That affiant is personally entitled to full payment or delivery of the property 13 claimed or is entitled to payment or delivery on behalf of and with the written authority of 14 all other successors who have an interest in the property. 15 16 17 18 19 20 21 22 23 That the affiant acknowledges that he understands that filing a false affidavit constitutes a felony in this state. I declare under penalty of perjury under the law of the State of Nevada that the foregoing is true and correct. EXECUTED this Day day of Month , 20 Yr. . __________________________________________ Affiant 24 25 26 27 28 2 Afft_of_Entitlement_to Estate.doc 8/11/2005 American LegalNet, Inc. www.USCourtForms.com