Approved, SCAO

Estate of

AFFIDAVIT OF DECEDENT'S SUCCESSOR
FOR DELIVERY OF CERTAIN ASSETS OWNED BY DECEDENT

1. I am decedent's successor assurviving

 spouse

adult child

other heir

devisee under the will dated

.

fiduciary or representative of

Name

2. Decedent died a resident of

More than 28 days have passed since decedent's death.

City, township, or village and county and state

3. No real property is included in the estate.

who is an heir or devisee and has a legal incapacity.

specify

on

Date

4. Decedent's estate, less liens and encumbrances, does not exceed $15,000 (as adjusted for cost of living as provided in MCL

700.1210).

5. An application/petition for the appointment of a personal representative is not pending or has not been granted in any jurisdiction.
A petition for assignment of an estate not exceeding $15,000 (as adjusted for cost of living) has not been filed with a court.

6. I am entitled to payment or delivery of the following property:

7. The name and address of each other person entitled to a share of the property and his/her proportion is as follows:

NAME

ADDRESS

RELATIONSHIP

SHARE %

    .

    .

8.  A copy of the death certificate is attached.

Signature

Name (type or print)

Address

City, state, zip

Subscribed and sworn to before me on

  ,

Date

County and state or other jurisdiction where acting

My commission expires:

Signature:

Notary public,

County and state or other jurisdiction where commissioned

NOTICE:  A false statement on this affidavit may subject the person swearing to the statement to prosecution for perjury.

PC 598   (9/11)   AFFIDAVIT OF DECEDENT'S SUCCESSOR FOR DELIVERY OF CERTAIN ASSETS OWNED BY DECEDENT

MCL 700.3983