AFFIDAVIT OF CLAIMING SUCCESSOR (SMALL ESTATE AFFIDAVIT) - Page 1 of 4 FC(2//1) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 IN THE CIRCUIT COURT OF STATE OF OREGON FOR THE COUNTY OF Probate Department In the Matter of the Small Estate of : , Deceased . ) ) ) ) ) ) ) Case No.: AFFIDAVIT OF CLAIMIN G SUCCESSOR (SMALL ESTATE AFFIDAVIT) [Chapter 595, Sections 13 and 22, Oregon Laws 2011; ORS 114.515] 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 named the personal representative under the decedI am a creditor and have not been paid the full amount owed to me within 60Creditors must check the box that applies: The decedent died intestate and without heirs. I have attached writtenauthorization from the Division of State Lands allowing me to file this smallestate proceeding; or Authorization from the Division of State Lands is not required because thedecedent dies 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 confidential death record is concurrently filed STATE OF OREGON County of ) ) ) ss. American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF CLAIMING SUCCESSOR (SMALL ESTATE AFFIDAVIT) - Page 2 of 4 FC(2//1) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 3.. Real Property Fair Market Value [attach a legal description] [maximum total value $200,000] Personal Property Fair Market Value [PERs accounts, bank accounts, jewelry, etc.] [maximum total value $75,000] 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 County. This small estate affidavit be filed in County because [check at least one that applies]: The decedent died in County. At death, the decedent lived in or had a home in County.The decedent had property located in County at death or when thisaffidavit 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 Oregoncourt 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). 7.The heirs. The heirs of the decedent, and their addresses are: Name of each heir Relationship to decedentLast-known address American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF CLAIMING SUCCESSOR (SMALL ESTATE AFFIDAVIT) - Page 3 of 4 FC(2//1) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 8.The devisees. [This part only applies if the decedent left a will. If the decedent -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, ifthe decedent died testate. I will do this by delivering or mailing the papers to theheirs and devisees at the last-know addresses. I will do this within 30 days after thisaffidavit 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, for - 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): Last-known address Type of claim & estimate or amount 12.Disputed Creditors. I, as affiant, dispute the following claims against the estate: Last-known address Type of claim & estimate or amount American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF CLAIMING SUCCESSOR (SMALL ESTATE AFFIDAVIT) - Page 4 of 4 FC(2//1) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 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 ormailing the papers to the creditor at the last-known address. I will do this within 30days 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 toeach of the following: Department of Human Services & Oregon Health Authority Estate Administration Unit PO Box 14021 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 thanthose listed in this affidavit may be barred unless:1)A claim is presented to the affiant within four months of the filing of theaffidavit at the address stated in part 1 of this affidavit; or2)A personal representative of the estate is appointed within the time allowedunder ORS 114.555.b.If this affidavit lists one or more claims which the affiant disputes, any suchclaim may be barred unless:1)A petition for summary determination is filed within four months of thefiling of this affidavit; or2)A personal representative of the estate is appointed within the time allowedunder 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: ( ) SUBSCRIBED AND SWORN to before me this day of , 20 . NOTARY PUBLIC FOR OREGON My Commission expires: American LegalNet, Inc. www.FormsWorkFlow.com