REAL ESTATE AFFIDAVIT COMMONWEALTH OF VIRGINIA VA. CODE § 64.2-510 Court File No. .................................................................... ................................................................................................................................................................................................................................. ................................................................................................................................................ NAME OF DECEDENT Circuit Court ....................................................................... DATE OF DEATH ............................................................................................................................................................................................................................................................. NAME AND ADDRESS OF SUBSCRIBER ............................................................................................................................................................................................................................................................. [ ] I have an interest as ............................................................................................................. in the real property of the decedent; AND/OR [ ] I qualified in .................................................................................................................................................................................................................... as NAME OF COURT the personal representative of the above-named decedent, who died intestate as to the real estate described herein, and who, at the time of death, was seized of real property in this jurisdiction, briefly described as ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. The name and last known address of decedent's heirs are: NAMES OF HEIRS ADDRESSES RELATIONSHIP AGE ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ............................................................................................................................................................................................................................................................. ........................................................................ DATE _____________________________________________________ SIGNATURE OF SUBSCRIBER State/Commonwealth of ...................................................................... Subscribed and sworn to before me by [ ] City [ ] County of ............................................................................ ....................................................................................................................................................................................................................................................... PRINT NAME OF SIGNATORY this ........................... day of ............................................................................................. , 20 ........................ . _____________________________________________________ [ ] CLERK [ ] DEPUTY CLERK [ ] NOTARY PUBLIC My commission expires Registration No. VIRGINIA: In the Clerk's Office of the ................... Circuit Court this the foregoing AFFIDAVIT was filed and admitted to record. ...................... ................................................. ................................................................ day of ..................................................... , 20 ........... Teste: By: ______________________________________________ CLERK __________________________________ , Deputy Clerk FORM CC-1612 MASTER 10/12 American LegalNet, Inc. www.FormsWorkFlow.com