Small Estate Affidavit And Order Page 6

STATE OF ____________

COUNTY OF __________

The undersigned Distributee states that she has personal knowledge of

the facts stated in the foregoing Affidavit and that, to the best of her

knowledge, the facts contained in the Affidavit are true.

__________________________

SUBSCRIBED AND SWORN TO BEFORE ME by the said

______________________________ this ____ day of

_________________, 199__, to certify which witness by hand and seal of

office.

[SEAL]

Notary Public, State of

Notary's Printed Name:

Notary's Commission Expires:

SMALL ESTATE AFFIDAVIT AND ORDER

PAGE 6

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