SMALL ESTATE AFFIDAVIT
___________________________________, residing at _________________________________________
being duly sworn, deposes and says:
___________________________________, insured under policy number __________________________
issued by ____________________________________ died on the date of __________________________
leaving no will, and that no petition for the appointment of an executor or administrator of the decedent’s
estate has been granted, is pending or contemplated; that all of the bills, debts, expenses, taxes and charges
of whatsoever kind or nature of either said decedent or said Decedent’s Estate have been paid; and that the
gross value to the Decedent’s real and personal property, excluding exempt property, does not exceed
The following relatives of the decedent were surviving at the time of the decedent’s death:
Date of Birth
The names of heirs-at-law of the decedent are listed above and there are no others who could claim an
interest in the estate.
The undersigned recognizes that the Company will rely on this Affidavit, agrees to indemnify Life
Insurance Company from any claim of suit (including Attorney’s fees) filed arising out of the subject
policy, and request said Company to waive the requirement of administration and honor the instructions
attached to the affidavit.
(Signature of Affiant)
(Relationship of the Decedent)
Subscribed and sworn to before me this ________________ day of ____________________, 20________.
(SIGNATURE OF NOTARY PUBLIC)
(NOTARY STAMP OR SEAL)