IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE THIRD JUDICIAL DISTRICT In the Matter of the Small Estate of ) ) ) ) ) ) Deceased. STATE OF OREGON County of Marion ) ) ) Case No. AFFIDAVIT OF CLAIMING SUCCESSOR (SMALL ESTATE AFFIDAVIT) ss. 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] □ □ □ □ 2. I am an heir of the decedent, and the decedent left no will. I am a devisee of the decedent under the decedent’s will. I am named the personal representative under the decedent’s will. I am a creditor and have not been paid the full amount owed to me within 60 days of the decedent’s death. 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. The decedent. Name: Home Age: Soc. Sec. No. ______________________________________________________ Date of death: _______________ Place of death: ______________________ or mailing address: A certified copy of the death certificate is attached. Small Estate Affidavit - Page 1 of 4 FC (8/4/09) American LegalNet, Inc. www.FormsWorkFlow.com 3. The decedent’s estate. The following property is in the decedent’s estate: Real Property [attach a legal description] Fair Market Value [maximum total value $150,000] ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Personal Property [PERS accounts, bank accounts, jewelry, etc.] Fair Market Value [maximum total value $50,000] ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ [”Fair market value” means the value of the property on the open market (between unrelated 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 Marion County. This small estate affidavit should be filed in Marion County because [check at least one that applies]: □ □ □ The decedent died in Marion County. At death, the decedent lived in or had a home in Marion County. The decedent had property located in Marion County at death or when this affidavit is filed. Thirty or more days have passed since the decedent 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] □ □ 7. 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). The heirs. The heirs of the decedent, and their addresses, are: Name of each heir Relationship to decedent Last-known address ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Small Estate Affidavit - Page 2 of 4 FC (8/4/09) American LegalNet, Inc. www.FormsWorkFlow.com 8. The devisees. [This part only applies if the decedent left a will. If the decedent did not leave a will, write in “none.”] The devisees named in the decedent’s will, and their last-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 instructions). If one person is to receive the entire estate, state “entire estate” or “100% of residue” under “Property to be received.” If, for example, three people share the estate equally, state “one-third of residue” under “Property to be received.”] 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): Creditor’s name Last-known address Type of claim & estimate or amount ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ [If the estate has no creditors, write in “none.”] 12. Disputed claims. I, as affiant, dispute the following claims against the estate: Creditor’s name Last-known address Type of claim & estimate or amount ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ [If the estate has no creditors making claims the affiant disputes, write in “none.”] Small Estate Affidavit - Page 3 of 4 FC (8/4/09) American LegalNet, Inc. www.FormsWorkFlow.com 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 each of the following: Department of Human Services Estate Administration Unit PO Box 14021 Salem, Oregon 97309-5024 15. Oregon Health Authority 500 Summer Street NE E20 Salem, Oregon 97301 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) 2) b. 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 A personal representative of the estate is appointed within the time allowed under ORS 114.555. 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/ Deputy Court Clerk Small Estate Affidavit - Page 4 of 4 FC (8/4/09) American LegalNet, Inc. www.FormsWorkFlow.com