1.THERE IS A 45-DAY WAITING PERIOD AFTER THE DATE OF DEATH 2.$50,000.00 LIMITATION. REAL PROPERTY IS NOT TO BE INCLUDED 3.CERTIFIED COPY OF THE DEATH CERTIFICATE 4.ORIGINAL LAST WILL & TESTAMENT (If Decedent had a Will) 5.PROOF OF ASSET WITH DOLLAR AMOUNT (i.e. Bank Statement, Blue Book value print-out, correspondence from Insurance Co., etc.) 6.LIST OF ALL OUSTANDING DEBTS OWED BY THE DECEASED 7.COSTS: $107.50 and additional $5.00 if there is a will. $107.50, and an additional $5.00 if there is a will. $100.00 for bond premium for assets up to $20,000. For quotes on assets over $20,000.00 you will need to see a bond company representative. 8.WAIVER OF BOND FROM ALL HEIRS IF SEEKING A WAIVER OF BOND 9.COURT HOURS: MORNING COURT MON FRI 9:00 10:00 AM 10. ARE PAYABLE IN CASH OR CREDIT CARD ONLY AND DUE AT TIME OF FILING 11. ARE PAYABLE IN CASH OR CHECK ONLY AND DUE AT THE TIME OF FILING. 12.DRESS CODE: YOU MAY BE APPEARING BEFORE THE JUDGE, SO PLEASE DRESS APPROPRIATELY. (NO TANK TOPS, SHORTS, SPAGHETTI STRAPS OR T-SHIRTS WITH INAPPROPRIATE WRITING. HATS AND SUNGLASSES MUST BE REMOVED, ETC.) The undersigned, provisions of Tennessee Code Annotated § 30-4-101, et seq., would respectfully state under oath as follows: A. , died on the day of , , and was a resident of Shelby . B. CHECK APPROPRIATE PROVISION: The Decedent left no will; Assets of the estate do not exceed $50,000. The Decedent left a will and the will is attached to this Affidavit as Exhibit A; Assets of the estate do not exceed $50,000. C. The name, age, address, and relationship of each heir at law or beneficiary entitled to receive Name Address Age Relationship 1 of 3 D. excluding real estate. The names and addresses of all persons known to have possession of any vehicles, stocks, bonds, equipment, furniture and furnishings, and all other assets of the Decedent. Assets that pass automatically by operation of law, such as joint accounts are not included here. Items of Property Location Value (If necessary, attach separate sheet) Total assets of Probate Estate $ E. The following is a list of unpaid debts left by the Decedent and the name and address of each creditor and the amount due. Creditor Address Amount (If other debts, attach separate sheet) Total Debts of Estate $ 2 of 3 Total Assets of Probate Estate - Affiant evidences by signature hereto, subject to the penalties for perjury, that the statements contained in this Affidavit are true, are neither false nor misleading, and that the Affiant is mindful of all duties imposed by law. Affiant agrees to collect and preserve all assets of the estate and to file tax returns as required by law. Affiant also agrees to pay or reimburse funeral expenses, administration expenses, and creditors from the assets of the estate. Furthermore, Affiant agrees to distribute the laws of descent and distribution of the State of Tennessee. Affiant makes oath that the facts contained in the foregoing Affidavit are true and correct to the Sworn to this day of , 20 . Affiant Address Telephone No. The Affiant personally appeared before me, Bill Morrison, Clerk of the Probate Court of Shelby County, Tennessee, after being duly sworn, stated under oath, that the facts averred in the on and belief. This the day of , 20 By D. C. Bond shall be made for the total value of the estate as shown at the top of this page and in D on page 2 of 3, provided however that bond may be waived by a Judge of the Probate Court if all heirs at law request in writing that the bond be waived for the affiant. Since the will is not being proved and therefore is not admitted to Probate, a waiver requested by the will cannot be granted. 3 of 3 I, , state that I am the of , Deceased, and I hereby consent to the appointment of , as the Affiant of the Estate and I request that said Affiant serve without the requirement of making a bond. Signed: Address: Phone: Date: STATE OF COUNTY OF Sworn to and Subscribed before me this day of , 20 Notary Public My Commission Expires