Fillable COVER SHEET STATE OF ARKANSAS CIRCUIT COURT: PROBATE (Sebastian County)

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COVER SHEET STATE OF ARKANSAS CIRCUIT COURT: PROBATE (Sebastian County)

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COVER SHEET
STATE OF ARKANSAS
CIRCUIT COURT: PROBATE
1
6/1/2017
The probate reporting form and the information contained herein shall not be admissible as evidence in any
court proceeding or replace or supplement the filing and service of pleadings, orders, or other papers as
required by law or Supreme Court Rule. This form is required pursuant to Administrative Order Number 8.
Instructions can be found at www.courts.arkansas.gov.
County: District: Filing Date:
Judge: Division: Case ID:
Type of case (choose one):
In t
he Matter of:
Does this case involve the custody or support of minor children? Yes No
If yes, also file the completed Confidential Information Sheet.
Participant 1
Participant 2
Participant
Type
Participant
Type
Company/
Last Name
Company/
Last Name
Suffix
Suffix
First Name
First Name
DLN/State ID/
Contexte ID
DLN/State ID/
Contexte ID
Address
Address
City, State ZIP
City, State ZIP
Phone
Phone
Email
Email
Self-
represented
Yes No
Self-
represented
Yes No
DOB
DOB
Date of Death
Date of Death
Interpreter
needed?
Yes:
No
Interpreter
needed?
Yes:
No
Attorney of Record: Bar #:
Party representing: Atty Email Address:
Related Case(s): Judge: Case ID(s):
Manner of filing (choose one):
other language:
________________
other language: __________________
SEBASTIAN
12TH
(SE) Small Estate
(MFO) Original
DISPOSITION SHEET
STATE OF ARKANSAS
CIRCUIT COURT: PROBATE
1
6/1/2017
The probate reporting form and the information contained herein shall not be admissible as evidence in any
other court proceeding or replace or supplement the filing and service of pleadings, orders, or other papers
as required by law of Supreme Court Rule. This form is required pursuant to Administrative Order Number
8. Instructions can be found at www.courts.arkansas.gov
.
Case ID
: In the matter of:
Trial Type: (B) Bench Trial (N) Non-Trial
Was an interpreter used for this case? Yes No
For whom?
Language: Other:
Was any party self-represented for any portion of the case? Yes
If so, who?
Disposition Date:
Manner of Disposition (Choose one)
If consolidated, case ID:
Is this case set for review (typical
of guardianships)? Yes (MSSD) No (JUC0)
No indi
cates that the case is closed and no court monitoring is legally required.
If this
case involved guardianship (CSINF):
Guardian name:
first name last name
Child support ordered: New Modified Terminated N/A
Person ordered to pay child support:
first name last name
Was there an order of protection in this case? Yes No
No
If yes, person(s) protected under the order:
_________________________________________________________________
(MDJD) Judgment/Decree/Order
HOW TO FILL OUT AN AFFIDAVIT FOR COLLECTION OF SMALL ESTATE
Print the decedent’s name on the line marked:
“IN THE MATTER OF THE ESTATE OF___________________________, Deceased”
Print your name on the first line, and any additional person(s) who will be signing on the lines after
your name, located under the centered title of Affidavit for Collection, etc.
Write the decedent’s name again on the line located after “for the purpose of dispensing with
administration of the estate of _________________________”
ITEM NO. 1:
The decedent’s information; indicate the following information for the lines provided:
A. Name of deceased person
B. Age of deceased person upon death
C. Address of residency
D. County of residency
E. Address at death (address of home, address of nursing home, address of hospital)
F. Month, day and year of death
ITEM NO. 5:
The decedent’s property information; indicate the following information along with the approximate
value of item, and the name of the person(s) that is currently possessing the property:
A. Checking account #’s, balance, bank name, name on account
B. Savings account #’s, balance, bank name, name on account
C. Vehicle descriptions (make, model, year, and VIN #).
D. Household Items
E. Stock & Bonds (Certificate/Account #’s, # of shares, and Name of Corporation)
F. Life insurance policies (policy #, insurance company, value of policy, beneficiary)
G. Mineral/gas royalties/rights (exact location, value, who has possession)
H. Homestead (exact location/address, value of property, name on deed)
**** Value of Homestead does not count toward $100,000.00 limit of estate****
ITEM NO. 6:
Information of person(s) lawfully entitled to receive property of the decedent. List the following:
A. Include yourself and anyone else who may be entitled to any property of the
decedent, including surviving spouse, heirs or devisees of the decedent’s will if the
decedent had a will written prior to death.
Your name and requested information, and any other person(s) that are listed in the first opening paragraph
on the first page. All persons listed on the first page must sign (on line marked “Affiant”) and date the
document in front of a notary public.
Bring the completed document to the Circuit Clerk’s office to be filed. The filing fee for an Affidavit for
Collection of Small Estate is $25.00, plus $5.00 for each certified copy requested. If you only need one
certified copy, the total cost is $30.00. If you prefer, you may mail your completed Affidavit along with
a check or money order in the appropriate amount to:
Circuit Clerk, Attn: Probate Division, PO Box 1179, Fort Smith, AR 72902. Be sure to include a self-
addressed, stamped envelope for prompt return.
If real property is involved (i.e. Homestead) it is your responsibility to have a “notice of probate”
published in the Times Record and to file a proof of publication with the Clerk’s office.
**USE ADDITIONAL PAGES IF NECESSARY**
Ark. Code Ann. §28-41-101
IN THE CIRCUIT COURT OF SEBASTIAN COUNTY, ARKANSAS
GREENWOOD DISTRICT
PROBATE DIVISION ( )
IN THE MATTER OF THE ESTATE OF
Case No. PR-20 -
, DECEASED
AFFIDAVIT FOR COLLECTION OF SMALL ESTATE BY DISTRIBUTEE
, and
, for the purpose of dispensing with administration of the estate of
,state on oath the following:
1.. The decedent , aged , who resided at
___________________________________________, in Sebastian County, Arkansas, died at________________________,
on or about the day of , No petition for the appointment of a personal representative
for the decedent’s estate is pending or has been granted.
2. More than forty-five (45) days have elapsed since the decedent’s death.
3. The value, less encumbrances, of all property owned by the decedent at the time of death, excluding the
homestead of and statutory allowances for the benefit of the surviving spouse or minor children, if any, of the decedent, does
not exceed one hundred thousand dollars ($100,000.00).
4. There are no unpaid claims or demands against the decedent or the decedent’s estate, and the Department
of Humans Services furnished no federal or state benefits to the decedent (or, that if such benefit have been furnished, the
Department of Human Services has been reimbursed in accordance with state and federal laws and regulations).
5. An itemized description and valuation of the decedent’s personal property; a legal description and valuation
of the decedent’s real property, including homestead, if any; and the names and addresses of persons having possession
thereof or residing on any of the decedent’s real property, are:
Description of Property, and Extent Valuation Less In Possession Of: and Details of Encumbrances, If any: Encumbrances:
6. The names, ages, relationships to the decedent and residence addresses of the persons entitled to receive
property of the decedent as surviving spouse, heirs or devisees of the decedent’s will are:
Name Age Relationship Residence Address
_______________________________ _____ ____________ __________________________________________
_______________________________ _____ ____________ __________________________________________
**USE ADDITIONAL PAGES IF NECESSARY**
Ark. Code Ann. §28-41-101
_______________________________ _____ ____________ __________________________________________
_______________________________ _____ ____________ __________________________________________
THEREFORE, the distributee(s) of this estate shall be entitled to distribution of the property identified above, without the
necessity of an order of the court or other proceeding, upon furnishing a copy of this Affidavit, certified by the clerk, to any
person owing any money, having custody of any property, or acting as registrar or transfer agent of any evidence of interest,
indebtedness, property or right of the decedent.
DATED this day of , .
____________
AFFIANT
____________
[Address]
____________
[Telephone number]
_____________________________________________________________
[email Address]
STATE OF
COUNTY OF
Subscribed and sworn to before me, a notary public, on this date:
(SEAL) ________________________________
NOTARY PUBLIC
My commission expires: __________________
CERTIFICATE OF CLERK
The undersigned Clerk of the Circuit Court of Sebastian County, Arkansas, certifies that this is a true copy of an affidavit filed
in this Court on the ______ day of ____________________,________, that the affidavit remains on file and that no petition for
the appointment of a personal representative of the estate has been filed in this Court.
DATED this ___________ day of __________________, __________.
DENORA COOMER, CIRCUIT CLERK
By:______________________________________D.C.
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COVER SHEET STATE OF ARKANSAS CIRCUIT COURT: PROBATE (Sebastian County)

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Completed 18 July 2020

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