Cause No. _________________ Estate of ______________________________, Deceased � � � � � In County Court at Law No. ______ Fort Bend County, Texas Small Estate Affidavit On the dates indicated below, all of the Distributees of this estate and two disinterested witnesses personally appeared and, on their oath, did swear or affirm to the accuracy of the following facts, pursuant to Chapter 205 of the Texas Estates Code: A. Decedent, ____________________________________________, died on the ________ day of _______________________, 20______ in __________________ County, Texas. B. More than 30 days have elapsed since Decedent's death. C. Decedent was a resident of and domiciled in _________________ County, Texas, at the time of Decedent's death. [If not Ft. Bend County, the affidavit must include facts supporting venue in Ft. Bend County.] D. Decedent died without a will. E. No administration is pending or has been granted in Decedent's estate and none appears necessary. F. The value of the entire assets of the estate of Decedent, not including homestead and exempt property, does not exceed $50,000.00. G. The value of the entire assets of the estate of Decedent, not including homestead and exempt property, exceeds the known liabilities. H. Medicaid � check the accurate box: The Decedent did not apply for and receive Medicaid benefits on or after March 1, 2005. OR Decedent did apply for and receive Medicaid benefits on or after March 1, 2005, and the Medicaid Estate Recovery Program claim is listed as a liability in section "J" below. OR The Decedent did apply for and receive Medicaid benefits on or after March 1, 2005, but there is no Medicaid claim against the estate. [If this box is checked, applicant(s) must either (1) file a Medicaid Estate Recovery Program (MERP) certification that decedent's estate is not subject to a MERP claim or (3) include additional information proving that a MERP claim will not be filed.] Effective: October 15, 2015 Small Estate Affidavit, Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com I. All assets of the Decedent's estate and their values are listed here. NOTE: Community property is property acquired during marriage other than by gift or inheritance. Separate property is property owned before marriage or acquired by gift or inheritance during marriage. List with enough detail to identify exactly what the asset is. For example, give bank name and last four digits of an account number; give life insurance company name; give description of car plus VIN number; give address & legal description of real property. Description of Asset(s) Additional information If decedent was married, indicate: 1. whether each asset was community or separate property, and 2. facts that explain why the asset was community or separate If decedent was survived by a spouse, minor children, or unmarried adult children who lived with decedent, the list of known estate assets must indicate which assets applicant claims are exempt. See checklist for more information. Use additional pages as necessary. Value (Continue list as necessary. If list is continued on another page, please note.) Effective: October 15, 2015 Small Estate Affidavit, Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com J. All liabilities/debts of the Decedent's estate and their values are listed here. The affidavit must list all of Decedent's debts and other liabilities including all credit card balances, doctor and hospital bills, utility bills, etc. � everything owed by Decedent or Decedent's estate and not paid off. If none, write "none." If funeral debts or attorney's fees and expenses will be paid from estate assets, list them here. List with enough detail to identify the creditor & any account. Description of Liabilities / Debts: Balance Due (Continue list as necessary. If list is continued on another page, please note.) K. The following facts regarding Decedent's family history show who is entitled to what share of Decedent's estate, to the extent that the assets of Decedent's estate, exclusive of homestead and exempt property, exceed the liabilities of Decedent's estate. [Put check marks in the appropriate small boxes, and provide additional information as indicated.] Family History #1: Marriage. On the date of Decedent's death, Decedent was a single person. OR On the date of Decedent's death, Decedent was married to __________________________. The date they were married: __________________________________. Effective: October 15, 2015 Small Estate Affidavit, Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Family History #2: Children. Decedent had no children by birth or adoption, and Decedent did not take any children into Decedent's home to raise as a child. (Skip to Family History #4 if you check this box.) OR The following children were born to or adopted by Decedent. List all children, whether or not the child is still alive and whether or not parental rights were later terminated. If parental rights were terminated for any child, give details on separate page(s). Child's name Birth date, if known Name of child's other parent (Continue list as necessary. If list is continued on another page, please note.) Family History #3: Children, part 2. Answer if Decedent had any children. All of Decedent's children, by birth or adoption, were alive when Decedent died. OR The following of Decedent's children, by birth or adoption, died before the Decedent's death and were survived by children (or grandchildren or great-grandchildren): Name of deceased child (followed by the name of the deceased child's other parent in parentheses) Date child died Names of all children of the deceased child (if any of these children died before Decedent, use a separate page to give date of death, plus names & birth dates of all grandchildren) (Continue list as necessary. If list is continued on another page, please note.) AND/OR The following of Decedent's children, by birth or adoption, died before the Decedent's death and were not survived by any children, grandchildren, or great-grandchildren: Name of deceased child Date child died (Continue list as necessary. If list is continued on another page, please note.) If Decedent was survived by any children, grandchildren, or great-grandchildren, you do not need to answer Family History #4 about Parents or Family History #5 about Sisters and Brothers. You may skip to "L" (following #5). Effective: October 15, 2015 Small Estate Affidavit, Page 4 of 8 Ameri