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SMALL ESTATE AFFIDAVIT Collection of Personal Property State of Nebraska County of ______________ I, ____________________________________________________________________, upon being duly sworn, state on my oath that: 1. My post office address is: ___________________________________________________ 2. My residence address is: ___________________________________________________ 3. I am a legal successor to the decedent, ______________________________________, who resided at ____________________________________________________________. 4. I am entitled to be named as a successor to the decedent due to my relationship to the decedent, or I have a claim to the personal property of the decedent, namely: ________________________________________________________________________. 5. The decedent passed from this life on the _____ day of ________________, 20____. 6. The value of all of the personal property in the decedent's estate, wherever located, less liens and encumbrances, does not exceed twenty-five thousand dollars ($25,000). 7. At least thirty (30) days have elapsed since the death of the decedent. 8. No application or petition for the appointment of a personal representative is pending or has been granted in any jurisdiction. 9. I am entitled to payment or delivery of the property hereby claimed. THE FOREGOING STATEMENT IS MADE UNDER THE PENALTIES OF PERJURY.
________________________________________ Signature of Affiant State of Nebraska County of _______________________ Subscribed and sworn to before me on this the _____ day of _________________, 20____. ____________________________________ Notary Public, State of Nebraska Printed Name: ________________________ My Commission Expires: _________________ Disclaimer This form is provided without any warranty, express or implied, as to its legal effect and completeness. Please use at your own risk. If you have a serious legal problem, we suggest that you consult an attorney. Form #0002016 1
