Estate No. ................................................................... AFFIDAVIT OF NOTICE REGARDING ESTATE OF (who died on ..........................................................................................) ...................................................................................................................... I, the undersigned, state under oath/affirm the following: (Check the applicable block) 1. [ ] I am a personal representative of the estate of the deceased person named above. [ ] I am a proponent of the will of the deceased person named above. [ ] I am a person with an interest in the estate of the deceased person named above. 2. [ ] No notice was required to be given to any person pursuant to Va. Code � 64.2-508. OR [ ] I mailed or delivered within 30 days of qualification (or probate) a copy of the notice required by Va. Code � 64.2-508 to the following persons shown below: NAME a. b. c. d. e. ADDRESS WHERE MAILED OR DELIVERED DATE MAILED OR DELIVERED ........................................................................................................................................................................................................................................... ........................................................................................................................................................................................................................................... ........................................................................................................................................................................................................................................... ........................................................................................................................................................................................................................................... ........................................................................................................................................................................................................................................... (Continue on other side if more space is needed) (Check if applicable) 3. [ ] After exercising reasonable diligence, I have been unable to determine the address of the following persons to whom such notice is required: ........................................................................................................................................................................................................................................... ........................................................................................................................................................................................................................................... (Check if applicable) 4. [ ] After exercising reasonable diligence, I have been unable to identify the names and addresses of the persons described below (such as a child of the deceased person) who may be an heir or beneficiary: ......................................................................................................................................................................................................................................... ........................................................ DATE ________________________________________________________ SIGNATURE Commonwealth/State of ............................................................................ Subscribed and sworn to/affirmed before me on this by .................... [ ] City [ ] County of ............................................................................. day of ........................................................................... , 20 ........................ ..................................................................................................................................................................................................................................................... . PRINT NAME(S) ........................................................................................................................................................................................................................................................... ..................................................... DATE _______________________________________________________________________ [ ] CLERK [ ] DEPUTY CLERK [ ] NOTARY PUBLIC Notary Registration No. ......................................... My commission expires: ............................... NOTICE: This affidavit must be recorded in the Clerk's office where the personal representative qualified or the will was probated. VIRGINIA: In the Clerk's Office of the ......................................................................................................................................................... Circuit Court this ....................... day of ................................................................................. , ............................. . The foregoing Affidavit of Notice was this day admitted to record. Teste: ______________________________________________________, Clerk by: __________________________________________________, Deputy Clerk FORM CC-1617 MASTER 10/12 American LegalNet, Inc. www.FormsWorkFlow.com