Affidavit Of Heirship Form Page 2
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1
2Section IV
In case owner left no surviving spouse and no children or descendants of deceased children, then please furnish the following
information:
Name of Parents
Address
Living/Dead
Date of Death
Father
Mother
Give names of brothers and sisters or Owner:
Name
Relation
Address
Age
Living/Dead
Date of Death
Give names of children of deceased brother or sister:
Name
Child of
Age
Address
Living/Dead
State briefly, facts and circumstances (such as being a relative of, or attorney for Owner, etc.) which will show basis and
sources of information herein before giving:
The names of all heirs-at-law of the descendent are listed above and there are on others who could claim an interest in the estate.
__________________________________________
Affiant
Section V
Subscribe and sworn to before me on this _____________________day of _______________________________________________
My commission expires____________________________________________.
__________________________________________
Signature of Notary in and for__________________
NOTARY SEAL
____________________________________County,
State of __________________________________
__________________________________________
(Print, Type or Stamp the name of the Notary Public)
The above and foregoing affidavit is true and correct and we, the undersigned, being all the heirs at law of the owner, hereby agree to
indemnify and hold harmless the said COMPANY from any and all costs, reasonable attorney fees, actions, loss or damage which it
may suffer by virtue of payment to me (us) under and because of the said policy of insurance, annuity, supplemental contract, or
installment/interest certificate.
(All heirs must sign below.)
____________________________________________________
__________________________________________________
Witness Signature
Heir’s Signature
____________________________________________________
__________________________________________________
Witness Signature
Heir’s Signature
____________________________________________________
__________________________________________________
Witness Signature
Heir’s Signature
____________________________________________________
__________________________________________________
Witness Signature
Heir’s Signature
____________________________________________________
__________________________________________________
Witness Signature
Heir’s Signature
AGLC102318 Rev0113
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