STATE OF WISCONSIN,
IN THE MATTER OF
Transfer by Affidavit
($50,000 and under)
Register of deeds recording area
Name and return address
Note: Use black ink only.
parcel identification number
UNDER OATH, I STATE:
1. The decedent, with date of birth
was domiciled in
2. I am:
and date of death
County, State of
, with a mailing
an heir, having the following relationship to the decedent:
the person who was guardian of the decedent at the time of the decedent’s death.
trustee of a revocable trust created by the decedent.
3. The total gross value of the decedent’s property subject to administration in Wisconsin on the date of decedent’s
death was $
(not to exceed $50,000).
4. The decedent:
receive Medical Assistance/Medicaid.
receive Family Care and/or Partnership benefits (through a Managed Care
Organization – MCO/CMO).
receive benefits from the Community Options Program (COP).
receive benefits from