Form Dfs-Up-1243 - Estate Affidavit - Florida Page 2

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BENEFICIARY VERIFICATION
Under penalties of perjury, I declare that I have read this affidavit and that all of the information contained
herein is true.
Print Name and Mailing Address
Relationship
Age
Portion of Estate
To Decedent
_____________________________
___________
_____
_____%
$_________
_____________________________
_____________________________
Signature _________________________________
SS# _____________________________________
Print Name and Mailing Address
Relationship
Age
Portion of Estate
To Decedent
_____________________________
___________
_____
_____%
$_________
_____________________________
_____________________________
Signature _________________________________
SS# _____________________________________
Print Name and Mailing Address
Relationship
Age
Portion of Estate
To Decedent
_____________________________
___________
_____
_____%
$_________
_____________________________
_____________________________
Signature _________________________________
SS# _____________________________________
Print Name and Mailing Address
Relationship
Age
Portion of Estate
To Decedent
_____________________________
___________
_____
_____%
$_________
_____________________________
_____________________________
Signature _________________________________
SS# _____________________________________
Print Name and Mailing Address
Relationship
Age
Portion of Estate
To Decedent
_____________________________
___________
_____
_____%
$_________
_____________________________
_____________________________
Signature _________________________________
SS# _____________________________________
Print Name and Mailing Address
Relationship
Age
Portion of Estate
To Decedent
_____________________________
___________
_____
_____%
$_________
_____________________________
_____________________________
Signature _________________________________
SS# _____________________________________
Form DFS-UP-1243, Revised 01/03/2005

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