I, __________, being duly sworn, state:

1. Death

__________ died on __________, a resident of __________ County, State of __________.

2. Entitlement

I am the decedent's __________ and am entitled to collect the property described below.

3. Estate Value

The total value of the estate, less liens, is __________, which does not exceed the limit allowed by state law. At least the waiting period required by law has passed since the date of death, and no probate proceeding is pending.

4. Property

__________

5. Oath

I declare under penalty of perjury that the foregoing is true and correct, and I will distribute the property to those legally entitled to it.

Notary Acknowledgment

State of __________, County of __________.

On ____________________, before me, the undersigned notary public, personally appeared __________, proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to this instrument, and acknowledged that he/she/they executed the same.

Notary Public Signature: ______________________________ My Commission Expires: ____________