IN THE CHANCERY COURT FOR WILLIAMSON COUNTY, TENNESSEE ESTATE OF: ) ) NO. _____________ SMALL ESTATE AFFIDAVIT After being duly sworn, the deponent states: (1) The decedent, age _____, died on the ________ day of ________________, 20___, and was last a resident of Williamson County, Tennessee. (2) The decedent ( ) left a will, which is filed with this affidavit. ( ) did not leave a will. (3) The decedent left the following unpaid debts at death: CREDITOR ADDRESS AMOUNT ______________________________________________________________________________ ______________________________________________________________________________ (4) The decedent died owning the following personal property: ITEM LOCATION AND POSSESSION VALUE ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ (5) The decedent owned the following life insurance policies payable to the estate: INSURANCE COMPANY POLICY NUMBER AMOUNT ______________________________________________________________________________ ______________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com (6) The following are the devisees, legatees or heirs entitled to receive any of decedent’s property: NAME ADDRESS AGE RELATION ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Affiant elects(___) does not elect (____) to give notice to creditors in the manner required for regular administration. Affiant evidences by signature that, subject to the penalty for perjury, this affidavit is not false or misleading and the affiant is mindful of all duties imposed upon affiant by T.C.A. § 30-4-101 et seq. No clerk or assistant shall be liable as a result of services rendered to affiant in good faith in completing the affidavit based upon information furnished by affiant. ___________________________________ AFFIANT STATE OF ________________________ COUNTY OF ______________________ Personally appeared before me the said ______________________________, and after being duly sworn deposes and says that the facts averred in the above affidavit are true to the best of his/her knowledge, information, and belief, this _____ day of ____________________, 20___. _____________________________________ NOTARY PUBLIC/CLERK & MASTER (My Commission expires: __________) American LegalNet, Inc. www.USCourtForms.com CERTIFICATE I, Clerk and Master for the Chancery Court of Williamson County, certify that this is a court of record; that this is a true, full, and correct copy of the Small Estate Affidavit filed in this Court; that this Affidavit is still in full force and effect as of this date; and that the original of this Affidavit is on file in the office of the Clerk and Master for Williamson County, Tennessee. Witness my hand and seal, this ______ day of ___________________, 20___. _____________________________________ ELAINE B. BEELER, CLERK & MASTER By: _____________________________ Deputy Clerk BOND: ________________________ ________________________________ CLERK & MASTER American LegalNet, Inc. www.USCourtForms.com