I, being duly sworn according to law, declare that I reside at
Street Address
and that on
Date of Death
Name of Deceased
had permanent legal residence at
Complete Address of the Deceased
. I am the
Specify: widow, widower, child, father,
mother, sibling, other
Your Name
and as such am entitled to receive the decedent's estate under the laws of
Name of state/foreign state in the
United States or foreign country
where the deceased last had a
permanent legal residence
. To the best of my knowledge,
U. S. Department of State
AFFIDAVIT FOR THE SURVIVING SPOUSE OR NEXT OF KIN
*Provide information below to the extent that it is available.
VENUE
State
ss.
City
Name of Deceased
did/did not have a will or trust specifying the disposition of his or her estate.
NAME(S) OF SURVIVORS, IN ORDER OF KINSHIP
Please insert the name of living relatives in the following order of relationship: surviving spouse, children, father and/or mother, brothers and/or
sisters, other:
Date of Birth
Telephone Number Relationship
Address
Name
DS-5511
10-2008
Page 1 of 3
(Including City, State/or Country)
(mm-dd-yyyy)
CONSULAR OFFICES OF THE UNITED STATES OF AMERICA
(mm-dd-yyyy)
Date of Birth Telephone Number RelationshipAddress
Signature of Affiant
Subscribed and sworn to before me by
Type Name of Affiant
Date
Address of Notary Public
Signature of Notary Public Type Name of Notary Public
Name
Page 2 of 3
DS-5511
(mm-dd-yyyy)
click to sign
signature
click to edit
click to sign
signature
click to edit
The information on this form is requested to assist U.S. Consular Officers to fulfill the
requirements of 22 U.S.C. 2715c and determine the next-of-kin of an American citizen who
dies abroad. A U.S. Consular Officer, or a U.S. diplomatic Officer is required to serve as
"provisional conservator" of the personal effects of U.S. citizens who die abroad at the time
of their death if there is not a legal representative, partner in trade, or trustee appointed to
take care of the decedent's estate and if the responsibilities of a "provisional conservator"
are authorized by treaty by the authorities or usage of the country where the death occurs
or the decedent is domiciled. Additionally, in exceptional circumstances, a U.S. Consular
Officer may also serve as administrator of an estate. A U.S. Consular officer may only
release the personal effects of the decedent to a person who has qualified legally to take
care of the decedent's estate or, in appropriate circumstances, to the next of kin.
Providing the information in the affidavit is voluntary, but, failure to complete this form will
require the person claiming to be next-of-kin to obtain and present alternative documents
such as certified copies of Letters Testamentary, Letters of Administration, or trust
documents.
ROUTINE USES: The information solicited on this form may be made available to federal,
state, local, or foreign government entities for administrative or law enforcement purpose,
including for the notification of kin or judicial matters involving contested estates and
related issues.
PRIVACY ACT STATEMENT
DS-5511
Page 3 of 3
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome