By executing this affidavit, a Petitioner declares the following statement: (1) the total amount of insurance proceeds payable by the insurance company is below $11,000.00; (2) sixty days have elapsed since the insured individual’s death.Download
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Register of Wills of Chester County, Pennsylvania SMALL ESTATE AFFIDAVIT UNDER 20 Pa.C.S.A. §3101(d) For Insurance Proceeds ONLY NOT to be used for Settlement of Small Estates under 20 Pa.C.S.A. §3102 (Original Death Certificate Must Accompany this Form) Decedent File No. 15 - also known as Social Security No. Before the Register of Wills of said County , ___________________________________________________________ (name of petitioner ) who resides at being duly sworn, (address of petitioner ) deposes and says that , age , a resident of (Decedent) , in Ches ter County , departed this life, at (Township, Borough, City) (loca tion) on the day of , . The total amount of insurance proceeds payable by does not exceed (name of company) $11,000 and 60 days have elapsed since the death of the insured. The undersigned agrees payment can not be made under this Affidavit if a written claim for same has been made by a Personal Representative of the estate and no other heir(s) having preference exist or have released their benefits to the undersigned . That said decedent left a spouse – whose name and residence is: Spouse Name: Residence: Phone Number: ________________________________________ and the following as next of kin: NAME RELATIONSHIP RESIDENCE & PHONE NUMBER That the above named are t he spouse and all the known next of kin of said decedent, to the best of my knowledge and belief. Your Petitioner avers there are NO KNOWN PROBATABLE ASSETS that would require an estate proceeding. Therefore, NO ESTATE WILL BE RAISED, AND LETTERS ARE NOT NECESSARY. Sworn and subscribed to before me this Signed by: Name of Petitioner day of , Register of Wills: Notary Public Kindly enter appearance in the above case this day of , My Commission Expires Attorney ID No. BE IT REMEMBERED, that as of this day of , There has been NO ESTATE RAISED FOR THIS DECEDENT AND NO LETTERS HAVE BEEN ISSUED BY THIS COURT. TERRI C LARK Register of Wills & Clerk of Orphans’ Court SMALL ESTATE AFFIDAVIT Instructions for Filing 1. ORIGINAL DEATH CERTIFICATE must accompany this Form . 2. $25 FILING FEE made payable to Register of Wills . We will accept cash or a money order . NO PERSONAL CHECKS ACCEPTED. 3. The form must be Notarized . This office does not have a Notary on staff. 4. Mailed filings must provide a self -addressed stamped envelope for return mailing of certification & receipt. 5. These Affidavits are not to be used for Settlement of Small Estates under 20 Pa.C.S.A §3102.