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STATE OF WISCONSIN,

COUNTY

IN THE MATTER OF

Transfer by Affidavit
($50,000 and under)
Decedent

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
address of
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:
did
did not
did
did not

receive Medical Assistance/Medicaid.
receive Family Care and/or Partnership benefits (through a Managed Care
Organization – MCO/CMO).
did
did not
receive benefits from the Community Options Program (COP).
did
did not
receive benefits from