Affidavit of Death and Heirship
Indicate N/A (Not Applicable) for any item that does not apply. SIGN IN THE PRESENCE OF A NOTARY
I, ________________________, of lawful age and under oath and penalty of fraud and perjury, hereby certify that
all statements herein are true and correct, based on my knowledge of the above named decedent. If the State makes
payment based on the information herein, I will indemnify and hold harmless the State, its officers and employees,
from any other valid claims to unclaimed property.
That I was personally well acquainted with the decedent for ____ years and my relationship with the decedent
was that of ________________ . That said decedent departed this life in the city of ________, county/parish of
_____________, in the state of _______________, on or about ____________, 20___.
1. Did the decedent leave a Will?
If yes, was the will admitted to probate?
If yes, where