IN THE CIRCUIT COURT OF THE STATE OFOREGON FOR THE COUNTY OF MULTNOMAH PROBATE DEPARTMENT In the Matter of the Small Estate of: CASE NO. AFFIDAVIT OF CLAIMING SUCCESSOR (Small Estate Affidavit) Filing Fee: $111 (ORS21.145 (4)) 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. [ ] [ ] The decedent died intestate and without heirs. I have attached written [ ] Authorization from the Department of State Lands is not required because the decedent died testate or left heirs. 2. The decedent: Name: Age: A certified copy of the death record is attached. Page 1 of 5 (PRINT Name of Deceased) A 3. Real Property (Land, house, rental property, etc.) Fair Market Value [attach a legal description- required] [maximum total value $200,000] Total all Real Property: $ Personal Property Fair Market Value [PERS accounts, bank accounts, jewelry,] [maximum total value $75,000] Total all Personal Property: $ 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 or insurance policies with specific individuals listed as beneficiaries).] 4. Affidavit should be filed in Multnomah County. This small estate affidavit should be filed in Multnomah County because [check at least one that applies]: [ ] The decedent died in Multnomah County. [ ] At death, the decedent lived in or had a home in Multnomah County. [ ] The decedent had property located in Multnomah 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] [ ] 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 Affidavit of Claiming Successor 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 Name of each devisee Last known address 9. Notice to heirs and devisees. I promise to give to each heir and 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 [The will, if one exists, governs who gets what. If no will exists, the laws of intestacy ee people share 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): Page 3 of 5 Affidavit of Claiming Successor American LegalNet, Inc. www.FormsWorkFlow.com Last-known address Type of claim & estimate of amount 12. Disputed claims. I, as affiant, dispute the following claims against the estate: Last-known address Type of claim & estimate of amount 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 State. Within 30 days after this affidavit is filed with the court, I promise to mail or deliver a copy of the affidavit showing the date of filing to the Department of Human Services (DHS) and the Oregon Health Authority at the following address: Department of Human Services Estate Administration Unit PO Box 14021 Salem, OR 97309-5024 (Pursuant to OAR 943-001-015(1)(h), mailing notice to DHS at the address above is considered giving notice to the Oregon Health Authority.) 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 Affidavit of Claiming Successor 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 (sign in front of Notary Public) Telephone Number: ( ) . Signed and sworn to before me on , 20. By Notary Public My commission expires Page 5 of 5 Affidavit of Claiming Successor American LegalNet, Inc. www.FormsWorkFlow.com