IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF DESCHUTES In the Matter of the Small Estate of ) ) Case No. ) Deceased. ) AFFIDAVIT OF CLAIMING SUCCESSOR ) (SMALL ESTATE AFFIDAVIT) ) STATE OF OREGON ) ) ss. County of Deschutes ) I swear that the following statements are true: 1. The affiant. My name and address are: I have authority to file this affidavit because: [check at least one that applies] I am an heir of the decedent, and the decedent left no will. I am a creditor and have not been paid the full amount owed to me within 60 days of the Creditors must check the box that applies: The decedent died intestate and without heirs. I have attached written authorization from the Division of State Lands allowing me to file this small estate proceeding; or Authorization from the Division of State Lands is not required because the decedent died testate or left heirs. 2. The decedent. Name: Age: Soc. Sec. No. Home or mailing address: Date of death: Place of death: A certified copy of the death certificate is attached. Page 1 of 5 Small Estate Affidavit American LegalNet, Inc. www.FormsWorkFlow.com 3. . Real Property [attach a legal description] Fair Market Value [maximum total value $200,000] Personal Property [PERS accounts, bank accounts, jewelry, etc.] Fair Market Value [maximum total value $75,000] parties), not reduced to reflect debts owed against the property. Do not include property that transfers automatically to others following death (such as joint bank accounts).] 4. Affidavit should be filed in Deschutes County. This small estate affidavit should be filed in Deschutes County because [check at least one that applies]: The decedent died in Deschutes County. At death, the decedent lived in or had a home in Deschutes County. The decedent had property located in Deschutes County at death or when this affidavit is filed. Thirty or more days have passed since the decent died. 5. No probate estate exists. No application or petition for the appointment of a personal representative has been granted in Oregon. [This means that no Oregon court has opened a probate estate for the decedent.] 6. Is there a will? [Check the one that applies] The decedent died testate (did leave a will). The original will (not a copy) is attached. The decedent died intestate (did not leave a will). Page 2 of 5 Small Estate Affidavit American LegalNet, Inc. www.FormsWorkFlow.com 7. The heirs. The heirs of the decedent, and their addresses, are: Name of each heir Relationship to decedent Last-known address 8. The devisees. [This part only applies if the decedent left a will. If the decedent did not -known addresses, are: Name of each devisee Last-known address 9. Notice to heirs and devisees. I promise to give to each heir and each devisee, if any, (1) a copy of this affidavit showing the date of filing and (2) a copy of the will, if the decedent died testate. I will do this by delivering or mailing the papers to the heirs and devisees at the last known addresses. I will do this within 30 days after this affidavit is filed with the court. 10. Who gets what? The following people are entitled to the following property: Name of heir or devisee Property to be received [If a will exists, the will governs who gets what. If no will exists, the laws of intestacy apply (see the instruction- Page 3 of 5 Small Estate Affidavit American LegalNet, Inc. www.FormsWorkFlow.com 11. Creditors. Reasonable efforts have been made to ascertain the creditors of the estate. The following expenses of or claims against the estate remain unpaid (including reimbursement owed to someone who paid claims or expenses): -known address Type of claim & estimate or amount 12. Disputed claims. I, as affiant, dispute the following claims against the estate: -known address Type of claim & estimate or amount [If the estate has no creditor 13. Notice to creditors. I promise to give each creditor listed in parts 11 and 12 above a copy of this affidavit showing the date of filing. I will do this by delivering or mailing the papers to the creditor at the last-known address. I will do this within 30 days after this affidavit is filed with the court. 14. Notice to Estate Administration. Within 30 days after this affidavit is filed with the court, I promise to mail a copy of the affidavit showing the date of filing to: Department of Human Services Oregon Health Authority Estate Administration Unit and 500 Summer Street NE PO Box 14021 Salem, Oregon 97301-1097 Salem, Oregon 97309-5024 15. Claims may be barred. Some claims against the estate may be barred unless specific things happen. A. Claims against the estate not listed in this affidavit or in amounts larger than those listed in this affidavit may be barred unless: 1) A claim is presented to the affiant within four months of the filing of the affidavit at the address stated in part 1 of this affidavit; or 2) A personal representative of the estate is appointed within the time allowed under ORS 114.555. Page 4 of 5 Small Estate Affidavit American LegalNet, Inc. www.FormsWorkFlow.com B. If this affidavit lists one or more claims which the affiant disputes, any such claim may be barred unless: 1) A petition for summary determination is filed within four months of the filing of this affidavit; or 2) A personal representative of the estate is appointed within the time allowed under ORS 114.555. I have read this affidavit. The statements it contains are true and correct to the best of my knowledge. Affiant Telephone Number: Signed and sworn to before me on , 20. Notary Public/Court Clerk Page 5 of 5 Small Estate Affidavit American LegalNet, Inc. www.FormsWorkFlow.com