AFFIDAVIT OF DEATH

FOR DISTRIBUTION OF DECEDENT'S PROPERTY

State of Alabama

I, ________, being of the legal age of consent, being duly sworn, do depose and state that I wish to claim property of the deceased, ________, whose social security number is ________ and who was a resident of the state of Alabama at the time of their death on ________. The date of death is evidenced by a certified copy of the Certificate of Death, attached hereto.

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The value of the decedent's entire estate subject to probate, wherever located, minus liens and encumbrances, is estimated to be $________ (________). The appropriate number of days have elapsed since the decedent's death before making this claim for funds. No application or petition for the appointment of a personal representative is pending or has been granted in any jurisdiction.

All debts of the decedent, including funeral and burial expenses and all unsecured debts, have been fully paid or provided for.

THEREFORE, I am claiming the following portion of the decedent's following funds:

________

All of the above funds shall be subject to probate.

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Oath or Affirmation of Affiant:

I certify under penalty of perjury under Alabama law that I know the contents of this Affidavit signed by me and that the statements are true and correct to the best of my knowledge.

______________________________
________, Affiant

______________________________
Date

STATE OF ______________________, COUNTY OF ______________________:

On this ________ day of __________________________, __________, before me,

____________________________, personally appeared ________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that they executed the same as for the purposes therein contained.

IN WITNESS WHEREOF, I hereunto set my hand and official seal.

______________________________
Notary Public

________________________
Title

My commission expires: _________________