Form 53-111-A (Back)(Rev.4-07/3)
NAME OF NIECE OR NEPHEW/
DATE OF NAME OF NIECE OR NEPHEW’S
CURRENT ADDRESS BIRTH DECEASED PARENT
Signed this ____ day of ____________________, ____________.
_____________________________________________________________________________________
(SIGNATURE OF AFFIANT)
State of _________________________
County of _______________________
Sworn to and subscribed to before me on _________________________________________________
(DATE)
by ________________________________________________________________________________
(NAME OF AFFIANT)
_____________________________________________________________________________________
(NOTARY SIGNATURE)
(Notary Seal) My commission expires: _____ day of __________________, _______.
THIS AFFIDAVIT MUST BE FILED IN THE COUNTY CLERK’S RECORD.
NAME OF CHILD/
DATE OF BROTHER’S OR SISTER’S
CURRENT ADDRESS BIRTH DATE OF DEATH
7. Provide the following information on the deceased’s brothers and/or sisters:
(If there are none, please state that below.)
8. Provide the following information on the deceased’s nieces and/or nephews born only to the deceased brothers/sisters in
Item 7, above:
(If there are none, please state that below. If additional space is needed, please provide information as an attachment.)
Claim
number:
Reported
owner name:
Resume Templates 1210 Document(s)
