IN THE CHANCERY COURT FOR HAMILTON COUNTY, TENNESSEE SMALL ESTATES ACT AFFIDAVIT TCA §§ 30-4-101—30-4-105. IN THE MATTER OF THE ESTATE OF PART 2 PROBATE DIVISION FILE N0. AFFIANT DECEASED 1. Decedent, _____, died on ______________________, in _____________________, _______________. 1.1 Age 1.2 Date 1.3 County 1.4 State 2. Decedent’s legal Tennessee residence on the date of death: 3. Decedent’s Last Will: (Check one box only) 3.1 Decedent left no Last Will. 3.2 Decedent left a Last Will that is attached to this affidavit as EXHIBIT A. 4. Decedent left at death the following unpaid debts: 4.1 4.2 CREDITOR 4.3 ADDRESS AMOUNT 4.4 Sub Total Sub Total from attached sheet(s) 4.6 Total 5. Pursuant to Tennessee Code Annotated § 30-4-103(1)(A)(v): (Check one box only) 5.1 I elect not to give notice to creditors. 5.2 I elect to give notice to creditors in the manner required for regular administration such that all the provisions of Tennessee Code Annotated §§ 30-2-306 — 30-2-321 shall apply. You must include all personal property or any interest in therein, owned by Decedent 6. Decedent died on the date of death, including insurance on Decedent’s life payable to the estate. owning personal Do not (a) insurance on Decedent’s life payable to beneficiaries other than the estate; property as (b) personal property held jointly with Decedent with right of survivorship. list: follows: This affidavit is not muniment of title for real estate. Tenn. Code Annot. § 30-4-102(4). 4.5 If other items, attach separate sheet(s). 6.1 ITEM 6.2 LOCATION AND POSSESSION 6.3 VALUE 6.4 If other items, attach separate sheet(s). 6.5 Sub Total Sub Total from attached sheet(s) 6.6 Total Page 1 of 3 pages. SMALL ESTATES ACT AFFIDAVIT FORM 005P, REV. 2010 NOV 15 American LegalNet, Inc. www.FormsWorkFlow.com 7. Decedent owned the following insurance policies payable to Decedent's estate: 7.1 7.2 INSURANCE COMPANY 7.3 POLICY NUMBER FACE VALUE 7.4 Sub Total If other items, attach separate sheet(s). Sub Total from attached sheet(s) 7.6 Total 9. Provide for each devisee, legatee, or heir who may be entitled to any of Decedent's property: 7.5 9.1 NAME 9.2 9.3 AGE RELATION 9.4 ADDRESS/ZIP CODE I am willing to collect and preserve all assets of this estate, pay all creditors and distribute the remainder according to the terms of the Will or according to the laws of descent and distribution of the State of Tennessee. T.C.A. §§ 30-2-305, 30-4-104(c). I shall file returns and pay the tax on property in this estate as required by title 67, chapter 8, parts 3-5, as now or hereafter amended, revised or recodified. T.C.A. § 30-4-104(d). SUBJECT TO PENALTY FOR PERJURY, I EVIDENCE BY MY SIGNATURE THE FACTS STATED IN THIS AFFIDAVIT ARE NOT FALSE OR MISLEADING AND ARE TRUE, CORRECT, AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF AND THAT I AM MINDFUL OF MY DUTIES AS IMPOSED UPON ME BY TITLE 30 CHAPTER 4 OF THE TENNESSEE CODE ANNOTATED. This ____ day of __________________, 20___. _______________________________ AFFIANT ______________________________________________________________ ADDRESS CHANCERY COURT OF HAMILTON COUNTY TENNESSEE ____________________ PHONE } Sworn to and subscribed before me this ____ day of ______________, 20___. S. LEE AKERS, CLERK & MASTER By__________________________________ PROBATE DEPUTY Page 2 of 3 pages. SMALL ESTATES ACT AFFIDAVIT FORM 005P, REV. 2010 NOV 15 American LegalNet, Inc. www.FormsWorkFlow.com SMALL ESTATES ACT AFFIDAVIT Enclosed is the Small Estates Act Affidavit. "Small Estate" means that the value of the personal property does not exceed $25,000.00 • The Small Estate proceeding cannot be done until 45 days from date of death. • Complete the Affidavit and bring it with you to Court. DO NOT SIGN THE AFFIDAVIT. If you need help, we will help you when you get to the Court. • Court Costs for the Affidavit Under the Small Estates Act is $96.50. • You will have to have a bond written by an insurance company. (Below is a list of those insurance companies who write bonds for small estates.) • You will need to call the insurance company and make arrangements with them to meet you in Probate Court. • The cost of the Bond is approximately $100.00. COMPANY Ingle-Knox 7506 Lee Highway Chattanooga, TN 37421 J. Pat Williams P.O. Box 8247 Chattanooga, TN 37421 Rowland, Slaten & Stephens P.O. Box 23685 Chattanooga, TN 37421 Alder & Cox 2110 Northpoint Blvd. Hixson, TN 37343 AGENT Reed McCroskey Joe McCroskey TELEPHONE NUMBER (423) 553-7770 Pat Williams (423) 894-2884 (423) 667-7244 Tom Rowland Charles Rowland Mort Brashears Johnny Cox (423) 954-9100 Probate Hours for the Small Estate are: Probate Court: (423) 877-3536 Tuesday -Friday After 10:30 a.m. & before 3:00 p.m. Hamilton County Courthouse, Suite 300, 625 Georgia Avenue, Chattanooga, Tennessee 37402 If you have any questions, please feel free to call us at 209-6615. Page 3 of 3 pages. SMALL ESTATES ACT AFFIDAVIT FORM 005P, REV. 2010 NOV 15 American LegalNet, Inc. www.FormsWorkFlow.com