Affidavit For Payment W/o Administration-Axa Equitable Life Insurance Company Form printable pdf download

AFFIDAVIT FOR PAYMENT WITHOUT ADMINISTRATION

{PLEASE PRINT OR TYPE}

NOTE

This affidavit should be completed by an adult in the following succession. (a) surviving spouse.

(b) child. (c) other next-of-kin of the deceased. If additional space is required for completion

of following answers use reverse side hereof showing number of question being answered

State of: ___________________________

County of: ___________________________

_______________________________} SS:

__________________________________________________________________________being first duly sworn, deposes and

(Name of person Making Affidavit and Relationship to Deceased) _______________________________________says that

_____________________________________________________died on ____________________________________________

That by reason of such death an amount has become payable to the said deceased’s estate under contract #___________________

On the life of ___________________________________________ issued by AXA Equitable Life Insurance Company.

That for the purpose of including the said AXA Equitable Life Insurance Company to make settlement of the amount payable without

requiring administration of the deceased’s estate the undersigned does answer as follows:

Did the deceased leave a will? IF so,

submit certified copy of the will

ANSWER

Have administration or probate proceedings been held, or are any pending or

contemplated? If so, do not submit this affidavit but furnish court certificate of

appointment of estate representative.

Residence of deceased

Street

City

State

Have last illness and funeral expenses of deceased been paid? (If not, give details,

names, addresses, amounts etc. and submit bills certified by such creditors as unpaid.)

Have all other debts of deceased, including any State or Federal taxes been paid? (If

not, give names of creditors, addresses, amounts, etc.)

(a)

The total value of decedent’s estate, (not including the amount payable under this

contract (determined after diligent inquiry, did not exceed the sum of

$____________.

(b)

If such value is over $1,000 how was it disposed of without administration of the

(b)

estate?

Was deceased survived by a spouse? If so, give name, address and SS#.

Give names, addresses, and SS# of all children of the deceased, including legally

adopted children, living at the death of the deceased (If none, so state.)

(a)

Did the deceased have any children, including legally adopted, who died prior to

his death? (If none, so state.) If so, give their names, dates of death and indicate

those who were adopted.

(b)

Did such children leave children surviving, including legally adopted? (If none

(b)

state) If so, give names and indicate those who were adopted.

10.

If answers to questions 8 AND 9 are “NONE” list the following persons who were

Name

Relationship

Address

SS#

alive at death of the deceased: (a) parents, (b) brothers and sisters, including half

(a)

brother and half sisters and , (c) if any brothers or sisters, including half-brothers and

(b)

half sisters, have died before the deceased list the names of their children.

(c)

11.

If any of the persons mentioned in answers to questions 7,8,9(b) or 10 were alive at

death of deceased, but have since died, give names and dates of death.

12.

If any of the persons mentioned in answers to questions 7,8,9(b) or 10 are not 21 years

of age, indicate names and dates of birth of those under 21. If all over 21, so state.

That in consideration of AXA Equitable Life Insurance Company making payment on the basis of this affidavit without requiring

administration of deceased’s estate the undersigned agrees to indemnify the said AXA Equitable for any loss, claim, damage or expense

arising from such payment.

Sworn to before me this ________ day of ________________ 20 ____ (Sign Here) _________________________________________

________________________________________

Name

Initial

Surname

_______________________________ (

Notary Public)

Affidavit For Payment W/o Administration-Axa Equitable Life Insurance Company Form

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