Affidavit Of Heirship Form
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1
2Affidavit of Heirship
State of ____________________________________________________ )
) ss.
County of ____________________________________________________ )
BEFORE ME, the undersigned authority, on this date personally appeared ___________________________ , affiant, and on
his/her oath says that he/she is over twenty-one years of age and is not incapacitated in any way; that he/she was personally
acquainted with ___________________________ , now deceased, who was the owner under a policy of insurance or the Payee
under an annuity, supplemental contract, or installment/interest certificate numbered __________________ , issued or reinsured by
One of the following Companies: American General Life Insurance Company, American Home Assurance, Delaware American Life
Insurance Company and The United States Life Insurance Company in the City of New York herein called the Company, and that the
statements hereinafter set forth, including answers to questions propounded, constitute a true, correct, and complete statement of the
facts and financial condition of said owner’s estate.
Section I
Did Owner leave a Will? _________ If so, has or will the Will be probated? _________ If Owner did not leave a Will, has or
will any administration be submitted in Probate Court in Owner’s estate? _________ If so, when and where? __________________
Were there any debts or obligation due by Owner at the time of death? _________ If so, give the following information:
To Whom Owing
Amount
Nature of Debt
Paid/Unpaid
Funeral Expense
Medical
What is approximate value of owner’s estate including all insurance? $__________________. Have all Federal Estate Taxes
and State Inheritance Taxes been paid? _____________ If not, what taxes have not been paid?
Section II
Was Owner married or single at time of death? _________ If married, to whom? __________________ Was the Owner ever
married to any other than the above-named person? _________ If so, give the following information: (List)
Name of Spouse
Living/Dead
Divorced
Date of Death or Divorce
Section III
If Owner has any children by any spouse, give the following information:
Name of Child
Age
Address
Living/Dead
Date of Death
By Which Spouse
If a deceased child left descendants, give the following information:
Name of Deceased____________________________________________
Name of Child
Age
Address
Living/Dead
Date of Birth
Name of Deceased____________________________________________
Name of Child
Age
Address
Living/Dead
Date of Birth
AGLC102318 Rev0113
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