AFFIDAVIT OF DEATH AND HEIRSHIP
STATE OF ____________________ )
) Subscribed and Sworn Under Oath
COUNTY OF ____________________ )
I, __________ (first) _____(MI) __________________(last), the affiant (“I” or “my” hereinafter), being of lawful age,
being first duly sworn, upon oath deposes and states:
I was well acquainted with the above named deceased individual (“deceased” hereinafter) for _____ number of years
and the answers and statements given in the following questionnaire are based upon my personal knowledge, true,
and correct. Further, I am not a direct heir of the named deceased individual.
1. What was your relationship to the deceased? ________________________________
2. The deceased departed his/her life on __________ (month) ______ (day), _________(year) in
__________________ (county or city), _____________________ (state). He/She was ________ years old.
3. The deceased owned the mineral property listed in the reference boxes above. YES / NO (circle one)
4. The described property was / was not (circle one) occupied by the deceased individual as his/her
5. The described property is / is not (circle one) occupied by the deceased’s surviving spouse.
6. The described property was property acquired by the deceased before / during (circle one) his/her most
7. How was the described property acquired by the deceased? (circle one) Inherited / Purchased / Gifted
I was well acquainted with the deceased’s surviving family members, and the following statements and answers to
the following questions are based upon my personal knowledge and are true and correct:
8. Did the deceased leave a will? YES / NO (circle one)
9. In what states has the deceased's estate been probated? (if no probate, write "none")
10. The estate of the deceased currently DOES / DOES NOT (circle one) owe and debts to any person, business,
or government entity, including any state or federal taxes.
11. If you circled DOES on question 10, please describe all debts owed, including taxes, of the estate:
12. At the time of death, the deceased was MARRIED / WIDOWED / DIVORCED / SINGLE-NEVER MARRIED
13. If you circled married, what was the deceased’s surviving spouse’s name? __________________________
14. If you circled married, what is the address of the surviving spouse?
______________________________________(street) ________________________(city) ________(state)
15. How many times was the deceased married? 0 / 1 / 2 / 3 / 4 / 5 / 6 / 7 / 8+ times (circle one)