Small Estate Affidavit (For Insurance Proceeds Only)

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.