Arizona Department of Revenue
Escheated Estate Affidavit
ADOR 11168 (12/11)
Mail To: Arizona Department of Revenue - Unclaimed Property Unit - PO Box 29026 - Phoenix, AZ 85038-9026
1. Name of Decedent 1a. Date of Birth 1b. Date of Death
2. Name of Claimant
2a.
Relationship to Decedent
4. Name of Decedent’s Spouse:
Not married at time of death
3. Choose only one answer:
List the name of all related persons, as defined by A.R.S. §§14-2102 to 2103:
If the Decedent was not survived by spouse or descendents provide the parent information:
The Decedent does not have a valid Will as defined by A.R.S. §§14-2501 to 2517.
The Decedent did have a valid Will, as defined by A.R.S. §§14-2501 to 2517. Attach the Will to this Affidavit.
5. Name of Decedent’s Descendents
6. Name of Decedent’s Father
7. Name of Decedent’s Mother
5a. Relationship 5b. Date of Birth
6a. Father survived Decedent?
Yes
No
Yes
No
7a. Mother survived Decedent?
5d. Date of Death
6b. Father’s Date of Death
6b. Mother’s Date of Death
Descendent had no children
See attached list of additional descendents.
I swear and attest that all claims, assertions and signatures made in this affidavit are true and material and acknowledge that any false
statement in this affidavit may subject me to penalties related to perjury and the subornation of perjury.
Attach Decedent’s Birth AND Death Certificate to this Affidavit.
Attach both Birth AND the Death Certificates (if now applicable) for each Descendent to this Affidavit.
Attach Death Certificates (if now applicable) to this Affidavit.
4a. Spouse’s Date of Birth 4a. Spouse’s Date of Death
Notary Public Signature
State of County of
(Affi x Seal Here)
Claimant Signature Date
Subscribed and Affirmed before me by: this
day of , 20 .
