Affidavit And Agreement Supporting Claim For A Deceased Person Form

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Affidavit and Agreement Supporting
Claim for a Deceased Person
(Checks will be made payable to the Estate of the Deceased Person)
I, the undersigned Claimant, claiming for or through the below-identified decedent who was entitled to
claim certain property now held in custody by the Office of the State Treasurer, said property being specifically
referenced below by property identification number(s), after being duly sworn, do hereby affirm as follows:
D
O
I
:
ECEASED
WNER
S
NFORMATION
N
D
O
: _____________________________________________________________
AME OF
ECEASED
WNER
D
SSN: ______________________________________________________________________
ECEDENT
S
D
D
B
: ________________ D
D
D
: __________________
ECEDENT
S
ATE OF
IRTH
ECEDENT
S
ATE OF
EATH
P
C
: The above-named Deceased Owner was the rightful owner of property that the Office of the
ROPERTY
LAIMED
State Treasurer now associates with the following property identification number(s): ________________________.
P
S
:
ROBATE
TATUS
(Check and Complete ONLY ONE)
The Decedent’s Estate is Unprobated and no application or petition for the appointment of a personal
representative/executor, or successor, is pending or has been granted in any jurisdiction.
The Decedent’s Estate is currently being probated in the ____________________ County Probate Court.
The Decedent’s Estate was probated in the ____________________ County Probate Court and was closed
in accordance with the Maine Probate Code on ___________________ (date).
Other (please explain): ___________________________________________________________________
C
T
C
A
: I am entitled under the Maine Probate Code to
LAIMANT
S CAPACITY
O
LAIM AND ENTER
GREEMENT
place this claim and enter the below-stated A
because I am:
GREEMENT
(Check ONLY ONE)
Heir to the Decedent’s Unprobated Estate.
Personal Representative (Executor) of the Decedent’s CLOSED Probated Estate.
Personal Representative (Executor) of the Decedent’s OPEN Probated Estate.
Other: (Please explain) _____________________________________________________
A
: Claimant agrees to abide by the distribution of the Decedent’s assets as determined by applicable
GREEMENT
law, governing instruments and court orders, and to indemnify and hold harmless the Office of the State Treasurer
against any superior claim(s) made on the above-claimed property.
Claimant’s Signature: ________________________________________________
Date: ____________
Claimant’s Name (printed): _______________________________________________________________
Personally appeared before me the said Claimant and affirmed the above-stated facts as true and correct based upon
his/her own personal knowledge.
County _____________________________ State __________________
Subscribed and sworn before me on: _____________________________
(seal)
Notary Public: _______________________________________________
My commission expires: ________________.
R
: 03/21/06
EVISED

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