KANSAS
DEPARTMENT OF REVENUE
DIVISION OF VEHICLES
www.ksrevenue.org
CLAIM OF HEIR AND/OR
BENEFICIARY AFFIDAVIT
(Estate of No More than $40,000)
State of Kansas )
) ss.
County of
)
I,
, of lawful age, first being duly sworn state:
Name of Affiant(s)
(1) On, , died
Date Name of Deceased
Testate or
Intestate at
,
City and State
leaving an estate not exceeding $40,000 in value, and I have attached a certified copy of the death certificate hereto.
(2) That no petition for the appointment of an executor or administrator of the decedent's estate is pending or has been granted.
(3) That all unpaid debts, claims or demands against the decedent or the decedent's estate and all estate and inheritance taxes due, if
any, on the property transfers involved, have been or will be paid.
(4) That the following are the names, ages, relationships and addresses of the beneficiaries under the decedent's will* or heirs of the
decedent: (If more space is needed, attach additional page.)
Name Age Relationship Address
(5) That the decedent's estate consists of the following vehicle(s): (This form is intended for use of titling vehicle(s) into the names of
the beneficiaries under the decedent’s will* or heir(s) of the decedent. If there are more vehicles in the estate than space provided
herein, please complete a separate “Claim of Heir Affidavit”.)
Vehicle Value Vehicle(s) Information
¾ $ VIN Year Make Style
I certify to the best of my knowledge that the odometer reading for the above vehicle is: (no 10
th’s)
)
• Ø
and the reading is: Actual Exceeds Mechanical Limits Not Actual > WARNING-ODOMETER DISCREPANCY
¾ $ VIN Year Make Style
I certify to the best of my knowledge that the odometer reading for the above vehicle is: (no 10
th’s)
)
• Ø
and the reading is: Actual Exceeds Mechanical Limits Not Actual > WARNING-ODOMETER DISCREPANCY
¾ $ VIN Year Make Style
I certify to the best of my knowledge that the odometer reading for the above vehicle is: (no 10
th’s)
)
• Ø
and the reading is: Actual Exceeds Mechanical Limits Not Actual > WARNING-ODOMETER DISCREPANCY
(6) That affiant(s) has (have) the sole and exclusive right to succeed to the personal property of the decedent and that affiant(s) is
(are) over 18 years of age and is (are) legally competent in all respects to make this affidavit and to receive the personal property
listed herein, apportioned among the affiant or affiants, if more than one as follows:
.
* Attach a copy of the decedent’s will to this affidavit. (Refer to items 4 and 5 above.)
Wherefore, affiant(s) hereby request(s) that the vehicle listed in this affidavit be transferred to the affiant(s).
Signature(s)
Date
Hand Printed Name
Of Person(s) Signing Above
WARNING: Kansas statutes KSA 21-3711 provides that FALSIFYING INFORMATION ON ANY REQUIRED DOCUMENT IS A SEVERITY LEVEL 8, NONPERSON
FELONY
. KSA 21-3710 deals with forgery; FORGERY IS KNOWINGLY AND WITH INTENT TO DEFRAUD AND IS SEVERITY LEVEL 8 NONPERSON FELONY.
TR-83b www (Revised 07/10)
