FORM SUMMARY Name of Form: Transfer by Affidavit ($50,000 and Under) Form Number: PR-1831 Statutory Reference: §867.03, Wisconsin Statutes Benchbook Reference: PR 8-20 Purpose of Form: To transfer decedent’s assets not exceeding $50,000 (gross) to an heir, trustee of trust created by decedent, or person who was guardian of the decedent at the time of the decedent’s death for distribution. Who Completes It: The heir, guardian or trustee at the time of the decedent’s death. Distribution of Form: Original must be provided to the holder of the property. If required, a notice of affidavit or a copy must be sent by certified mail, return receipt requested, to the Department of Health Services. If real estate, a certified copy or duplicate original shall be recorded with the Register of Deeds for each county in this state which the property is located. Accompanying Forms: New Form/Modification: Modification; last update 04/08. Modifications: Updated notary section and format. Clarified and simplified language. Comments: All assets subject to administration should be listed on one form regardless of location. Transferee takes as fiduciary on behalf of all creditors and heirs. About this Form: This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office and a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. Approval Date: 10/07/2010 Release Date: 12/22/2010 Page 1 American LegalNet, Inc. www.FormsWorkFlow.com COUNTY STATE OF WISCONSIN, IN THE MATTER OF Transfer by Affidavit ($50,000 and under) Decedent Register of deeds recording area Name and return address Note: Use black ink only. parcel identification number UNDER OATH, I STATE THAT: 1. The decedent, with date of birth was domiciled in address of 2. I am: and date of death County, State of , , with a mailing . an heir, having the following relationship to the decedent: the person who was guardian of the decedent at the time of the decedent’s death. trustee of a revocable trust created by the decedent. . 3. The total gross value of the decedent’s property subject to administration in Wisconsin on the date of death did not exceed $50,000. 4. The total gross value of the decedent’s property subject to administration in Wisconsin at the date of decedent’s . death was $ 5. The decedent: did not did did not did receive Medical Assistance/Medicaid. receive Family Care and/or Partnership benefits (through a Managed Care Organization – MCO/CMO). did not receive benefits from the Community Options Program (COP). did did not receive benefits from the Wisconsin Chronic Disease Program. did was not patient or inmate of a state or county hospital or institution, or responsible for any was person owing an obligation to the state or county. If so, explain: The affiant lacks information to complete this section. see attached.) 6. If the decedent was ever married, complete the following: (If more than one spouse, deceased): Name of spouse ( living or Divorced from decedent at time of decedent’s death. Married to decedent did not receive benefits from the Community Options Program (COP). did The spouse did not receive benefits from the Wisconsin Chronic Disease Program. did The spouse The affiant lacks information to complete this section. 7. I ask that the following property be transferred to me under §867.03(1g), Wisconsin Statutes: PR-1831, 10/10 Transfer by Affidavit ($50,000 and under) This form shall not be modified. It may be supplemented with additional material. §867.03, Wisconsin Statutes American LegalNet, Inc. www.FormsWorkFlow.com . Transfer by Affidavit ($50,000 and under) Page 2 of 2 Case No. _______________ DESCRIPTION OF REAL ESTATE AND/OR PERSONAL PROPERTY TO BE TRANSFERRED (If real estate, list legal description and tax parcel number. If personal property, specifically describe property including name of financial institutions and account numbers, if any.) GROSS VALUE 8. By accepting the decedent’s property under this section, I assume a duty to apply the property transferred for the payment of obligations according to priorities established under §859.25, Wisconsin Statutes, and to distribute any balance to those persons designated in the appropriate governing instrument, as defined in §854.01, Wisconsin Statutes, or if there is no governing instrument, according to the rules of intestate succession under ch. 852, Wisconsin Statutes. 9. If a decedent or decedent’s spouse has received any of the benefits that are listed on page 1 of this affidavit or if unknown, a duplicate affidavit must be sent by certified mail with return receipt requested to the Estate Recovery Program for the State of Wisconsin, Department of Health Services prior to submission of this affidavit for recording. The proof of prior mailed notice should accompany the affidavit for recording, with the delivery date on the mail receipt being at least 10 days prior. State of County of Subscribed and sworn to before me on   Signature Name Printed or Typed Notary Public/Court Official Address Name Printed or Typed My commission/term expires: This document was drafted by: Print or Type Name Register of Deeds Office viewed the certified mail receipt. ONLY if this affidavit describes an interest in or lien on real estate, then a certified copy or duplicate original of this affidavit must be recorded with the register of deeds in each county in Wisconsin where the real estate is located. PR-1831, 10/10 Transfer by Affidavit ($50,000 and under) §867.03, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com TRANSFER BY AFFIDAVIT (§867.03, Wisconsin Statutes) (1c) DEFINITION. In this section, “guardian” has the meaning given in §54.01(10) or 880.01(3), 2003 statutes. (1g) GENERALLY. When a decedent leaves property subject to administration in this state which does not exceed $50,000 in value, any heir of the decedent, trustee of a revocable trust created by the decedent or person who was guardian of the decedent at the time of the decedent’s death may collect any money due the decedent, receive the property of the decedent and have any evidence of interest, obligation to or right of the decedent transferred to the affiant if the heir, trustee or guardian provides to the person owing the money, having custody of the property or acting as registrar or transfer agent of the evidences of interest, obligation to or right, or, if the property is an interest in or lien on real property, provides to the register of deeds preliminary to the recording required under sub. (2m), proof of prior mailed notice under sub. (1m) if applicable and an affidavit in duplicate showing all of the following: (a) A description of and the value of the property to be transferred. (b) The total value of the decedent’s property subject to administration in this state at the date of decedent’s death. (c) Whether the decedent or the decedent’s spouse ever received the family care benefit under §46.286, medical assistance under subch. IV of ch. 49, long-term community support services funded under §46.27(7) or aid under §§49.68, 49.683 or 49.685. (1m) NOTICE OF AFFIDAVIT. (a) Whenever an heir, trustee or person who was guardian of the decedent at the time of the decedent’s death intends to transfer a decedent’s property by affidavit under sub. (1g) and the decedent or the decedent’s spouse ever received the family care benefit under §46.286, medical assistance under subch. IV of ch. 49, long-term community support services funded under §46.27(7) or aid under §§49.68, 49.683 or 49.685, the heir, trustee or person who was guardian of the decedent at the time of the decedent’s death shall give notice to the department of health services of his or her intent. The notice shall include the information in the affidavit under sub. (1g) and the heir, trustee or person who was guardian of the decedent at the time of the decedent’s death shall give the notice by certified mail, return receipt requested. (b) An heir, trustee or person who was guardian of the decedent at the time of the decedent’s death who files an affidavit under sub. (1g) that states that the decedent or the decedent’s spouse received the family care benefit under §46.286, medical assistance under subch. IV of ch. 49, long-term community support services funded under §46.27(7) or aid under §§49.68, 49.683 or 49.685 shall attach to the affidavit the proof of mail delivery of the notice required under par. (a) showing delivery date that is not less than 10 days before the day on which the heir, trustee or person who was guardian of the decedent at the time of the decedent’s death files the affidavit. (2) RELEASE OF LIABILITY OF TRANSFEROR. Upon the transfer to the heir, trustee or person who was guardian of the decedent at the time of the decedent’s death furnishing the affidavit with an attached proof of mail delivery if required under sub. (1m) (b), the transferor is released to the same extent as if the transfer had been made to the personal representative of the estate of the decedent. (2g) OBLIGATION OF AFFIANT. By accepting the decedent’s property under this section the heir, trustee, or guardian assumes a duty to apply the property transferred for the payment of obligations according to priorities established under §859.25 and to distribute any balance to those persons designated in the appropriate governing instrument, as defined in §854.01, of the decedent or if there is no governing instrument, according to the rules of intestate succession under ch. 852. An heir or guardian may publish a notice to creditors in the same manner and with the same effect as a trustee under §701.065. This subsection does not prohibit any appropriate person from requesting administration of the decedent’s estate under §856.07 or ch. 865. (2m) RECORDING OF AFFIDAVIT. (a) If an affidavit under sub. (1g) describes an interest in or lien on real property a certified copy or duplicate original of the affidavit shall be recorded in the office of the register of deeds in each county in this state in which the real property is located. (b) For purposes of a transfer under this section of an interest in or lien on real property, the recording of the affidavit copy or duplicate original constitutes the transfer to the affiant under sub. (1g) of the evidence of the interest in or lien on real property. (3) APPLICABILITY. This section is additional to §109.03(3) for payment of decedent’s wages by an employer directly to the decedent’s dependents. Address for: Department of Health Services Estate Recovery Program P. O. Box 309 Madison, WI 53701-0309 NOTE: If you are providing a copy of this affidavit to the Estate Recovery Program or a financial institution, include decedent’s social security number on a separate document. PR-1831, 10/10 Transfer by Affidavit ($50,000 and under) §867.03, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. American LegalNet, Inc. www.FormsWorkFlow.com