This Affidavit must be completed by a third disinterested party (Affiant) who will not benefit from the decedent’s estate. Do not
complete this form if the decedent left a will that was probated in court or there has been some other type of court determina-
tion to the estate.
Affidavit of facts concerning the identity of Heirs for the Estate of: _____________________________________________
Before me, the undersigned authority, on this day personally appeared: ________________________________________
(“Affiant”) who, being first duly sworn, upon his/her oath states:
1. My name is: ___________________________________________________________________________________ .
I live at: _______________________________________________________________________________________
I am personally familiar with the family and marital history of: ______________________________________________
(Decedent), and I have personal knowledge of the facts stated in this Affidavit.
2. I knew the decedent from ________________until ________________ Decedent died on ______________________ .
Decedent’s place of death: ________________________________________________________________________
At the time of decedent’s death,
CITY STATE COUNTY
decedent’s residence was: ________________________________________________________________________
CITY STATE COUNTY
NAME OF SPOUSE
DATE OF DATE OF DATE OF
MARRIAGE DIVORCE SPOUSE’S DEATH
3. Provide the following information on the deceased’s marital history:
(If never married, please state that below.)
NAME OF CHILD/
DATE OF NAME OF CHILD’S DATE OF
CURRENT ADDRESS BIRTH OTHER PARENT CHILD’S DEATH
4. Provide the following information on the deceased’s natural born and adopted children:
(If there are none, please state that below. If additional space is needed, please provide information as an attachment.)
NAME OF CHILD/
DATE OF NAME OF GRANDCHILD’S
CURRENT ADDRESS BIRTH DECEASED PARENT
5. Provide the following information on the deceased’s grandchildren, born only to the deceased children in Item 4, above:
(If there are none, please state that below.)
DECEASED’S PARENT’S NAME/ PARENT’S DATE
PARENTS CURRENT ADDRESS OF DEATH
6. If the decedent never married and did not have any children, provide the following information on the deceased’s parents:
MOTHER
FATHER
53-111-A
(Rev.4-07/3)
Claim
number:
AFFIDAVIT OF HEIRSHIP
THIS AFFIDAVIT MUST BE FILED
IN THE COUNTY CLERK’S RECORD.
Reported
owner name:
Resume Templates 1210 Document(s)
