IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF POLK In the Matter of the Small Estate of __________________________ Deceased. STATE OF OREGON County of Polk ) ) ) ) ) ) ) ) Case No.______________ AFFIDAVIT OF CLAIMING SUCCESSOR (SMALL ESTATE AFFIDAVIT) ss. I swear that the following statements are true: 1. THE AFFIANT. NAME_________________________________________TELEPHONE____________________ ADDRESS___________________________________________________________________ I have authority to file this affidavit because: (check at least one which applies) □ □ □ 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 AND the original will is attached. (NO COPIES OF WILL ACCEPTED) 2. THE DECEDENT. NAME_________________________ AGE______ SOCIAL SECURITY NO._______-______-_______ ADDRESS____________________________________________________________________ DATE OF DEATH_______________________________ PLACE OF DEATH______________________ A certified copy of the death certificate is attached hereto. 3. THE DECEDENT’S ESTATE. Real Property (attach 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) __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 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). Small Estate Affidavit July 2010 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com 4. AFFIDAVIT SHOULD BE FILED IN POLK COUNTY. (Thirty or more days have passed since the decedent died. Check at least one that applies) □ □ □ □ The decedent died in Polk County. At death, the decedent lived in Polk County. The decedent had property located in Polk County at death or when this affidavit is filed. No probate estate exists. No application or petition for the appointment of a personal representative has been granted in Oregon. (THIS BOX MUST BE CHECKED). 5. THE HEIRS. (List separately; attach separate sheet if necessary) Name Relationship Last Known Address ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ____________________________________________________________________________________ 6. THE DEVISEES. (Only applies if the decedent left a will. Write “NONE” if no will has been left. List separately) Name Last Known Address ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 7. 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. Name of Heir or Devisee Interest ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ If a will exists, the will governs who gets what. If no will exists, the laws of intestacy apply (as per instructions). If one person is to receive the entire estate, write “entire estate” or “100% of residue” under Interest. Small Estate Affidavit July 2010 Page 2 American LegalNet, Inc. www.FormsWorkFlow.com 8. 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). Name of Creditor Claim Type & Amount Last Known Address ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 9. NOTICE TO CREDITORS. I promise to give each creditor listed in 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 filing this affidavit with the court. 10. 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 ESTATE ADMINISTRATION UNIT PO BOX 14021 SALEM, OREGON 97309-5024 11. BARRED CLAIMS. 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 (1) of this affidavit; or 2. A personal representative of the estate is appointed within the time allowed under ORS 114.555. 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 (_______)_________________ Affiant Telephone Number SIGNED AND SWORN TO before me on ________________________________, 200___. _________________________________________ Notary Public/Deputy Court Clerk Small Estate Affidavit July 2010 Page 3 American LegalNet, Inc. www.FormsWorkFlow.com