Small Estate Affidavit For Nonresident Decedents - Washington Department Of Revenue

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Small Estate Affidavit for
Nonresident Decedents
This Affidavit may be used if the owner of the unclaimed personal property at issue was not a resident of the State of
Washington on the date of his or her death. Claimants should use the “Affidavit of Successor” form if the owner was a
resident of the State of Washington at the time of his or her death.
Use this form if the following is true to the best of your knowledge
That the name and address of the undersigned claimant are as follows:
Decedent’s Name:
Claimant’s Name:
Address:
City:
State:
Zip:
The decedent was, at the time of their death, a resident of the state of
.
(Attached to this affidavit is a photocopy of the decedent’s death certificate.)
The decedent did not leave a will.
The estate was not probated.
No application or petition for the appointment of a personal representative is pending or has been granted in any
jurisdiction.
Property description
The undersigned claimant claims the following personal property, which property is subject to probate:
Company Reporting Property
Property/Amount Claimed
Your Responsibility
As the claimant you are responsible for understanding the small estate laws in the state where the deceased was a resident.
You are responsible for the funds we pay you and if another legitimate heir comes forward, you will have to pay them their
portion of the funds you received.
The undersigned claimant bears responsibility for following the laws of the decedent’s state of residence and agrees to
indemnify and hold harmless the State of Washington against any liability arising from the State’s payment or delivery of the
property to the undersigned claimant.
(Claimant’s Signature)
(Seal)
(Notary Signature)
Dated this
day of
,
(yr)
Subscribed and sworn (or affirmed) to by:
Notary in and for the State of
(Claimant) before me this
My commission expires
day of
,
(yr)
Residing at
REV 80 0053 (2/21/08)
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