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RECEIVED 10/13/2006 at 10:52 AM
RECEIVING # 923321
BOOK: 636 PAGE: 755
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
000755
.
WYOMING AFFIDAVIT OF COLLECTION OF ESTATE ASSETS
In accordance with Wyo. Stat. Ann. §§ 2-1-201 and 2-1-202
A copy of this affldwlt must first be filed with the county clerlr of a WyomIng court of competent Jurlsc lctlon with a
certified copy atúlched to this affidavit.
To: Wells Fargo & Company
P.O. Box 3055
Portland, OR 97208
Certified Copy of Decedent's
Death Certificate to be attached
to this AffidavIt/Declaration
STATE OF WYOMING ~
COUNTY OF LId Gò IJ
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undersigned, first being duly m upon oath, state:
1. I am the claiming successor of the decedent because I am the
decedent.
2. Name of the decedent: /Jo,"-^"d- 4.t,.{ pç~ J6,vt!!.?
A /
3. Date of death: ~""'-# I)..) 1- 00' ,
4. State of decedent's residence at date of death: W !7Õ/L.. I..)"
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5. Place of death: G..r»v___¡ WjÞAA /1] (city and state)
6. The value of the entire estate, wherever located, less liens and encumbrances, does not exceed $150,000.
7. At least thirty (30) days have elapsed since the death of the decedent as shown in a certified or authenticated copy of the
decedenfs death certificate attached to the affidavit.
(Name. of person signing this affidavit) the
#-K-{ ¡, ~ c£. of the
(describe relationship to decedent)
8. There are no other distributees of the decedent having a right to succeed to the property under probate proceedings.
9. No application or petition for the appointment of a personal representative is pending or has been granted in any
jurisdiction.
10. I am entitled by law to payment or delivery of the property, and I request that the following described property be paid,
delivered, ortransferTed to me: a.c...d:..+~~9CZS ~fø'7 .
/lc.~i ,4-~~,<'.,.;h (;;~ WJ¡~ ~é) ð~A: ~,-v t-J~o~0
11. All statements in this affidavit are true and correct and I acknowledge that any false statement may subject the person
or persons herein claiming to penalties relating to perjury under the laws of the State of Wyoming and any other
applicable law.
.
&t~ma~~ve-:~- <
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Name (type or print)
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Address
CN) v e-Y c.J '" if '1.1'] 7
City, state, zip , v
County of
Uncoln
USA HOKANSON - NOTARY PUBLIC
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State of
Wyoming
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State of Wyom~ AfIIdivit of 4re does not ex $150,000
OPR6496WY (9-04 82114FO)
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My Commission Expires August 16, 2009
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