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AFFIDAVIT OF DISTRIBUTION
STATE OF WYOMING )
)55.
COUNTY OF LINCOLN )
I, Dennis W. Lancaster, personal representative of the Estate of Sybil W. Lancaster,
being first duly sworn, on oath, deposes and states that I am making this affidavit pursuant
to W.S. § 2-1-201, as distributee, as hereinafter set forth, and that I make the following
statements in connection therewith:
1. That Delmar C. Lancaster, became deceased May 21, 2006, in S1. George,
Washington County, Utah; that said decedent died intestate; that the decedent at the time
of his death was survived by his wife Sybil W. Lancaster, and Sybil W. Lancaster was
named beneficiary of that certain life insurance policy on the life of Delmar C. Lancaster
with Beneficial Financial Group, policy No.BL0984808 and that Sybil W. Lancaste'rwas the
named beneficiary of said policy and the only party entitled to the proceeds thereof; that
a copy ofthe Certificate of Death of Delmar C. Lancaster is attached hereto as Exhibit "AN.
2. That Sybil W. Lancaster, the named beneficiary of the above referred to
policy became deceased on August 10, 2006, in Afton, Lincoln County, Wyoming and at
the time of her death was the named beneficiary of the above entitled policy and was
entitled to the payments thereof; that Dennis W. Lancaster is the personal representative
of the estate of Sybil W. Lancaster and that there are no assets of the estate other then
the proceeds from this policy that would be subject to distribution; that a copy of the
Certificate of Death of Sybil W. Lancaster is attached hereto as Exhibit "B"
3. That the value of the entire estate of said decedent Sybil W. Lancaster,
wherever 'located, does not exceed the value of One Hundred Fifty Thousand Dollars
($150,000).
4. That more than thirty (30) days have elapsed since the of death of the
Sybil W. Lancaster.
5. That no application for the appointment of a personal representative of said
decedent is pending or has been granted in any jurisdiction.
6. That the estate of Sybil W. Lancaster, Dennis W. Lancaster personal
representative, is the sole and only party entitled to the proceeds of the above referred to
insurance policy; that there are no other distributees of the Sybil W. Lancaster having a
right to succeed to any of the property of said decedent under probate proceedings, and
RECEIVED 11/13/2006 at 10:41 AM
RECEIVING # 924289
BOOK: 639 PAGE: 804
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
'<q
0924289
000805
that therefore, the following named distributee is entitled to payment and delivery of
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proceeds of the above referred to policy:
The Estate of Sybil W. Lancaster, Dennis W. Lancaster, personal representative.
7. That among the assets owned by the decedent Sybil W. Lancaster at the
time of her death is the following:
a. Funds held by the Beneficial Financial Group due and payable under
policy BL09840808 on the life of Delmar C. Lancaster deceased , Sybil
W. Lancaster, beneficiary.
8. That an executed copy of this Affidavit is being presented to Beneficial
Financial Group in compliance with W.S. § 2-1-201 (a) and that said party is requested to
pay the proceeds of said policy of any other funds in said account that were due and owing
to the decedent, together with any interest and dividends thereon to the distributees above
named;
Executed at Afton, Wyoming, this 3' I f I day 0
STATE OF WYOMING )
)ss
COUNTY OF LINCOLN )
The foregoing instrument was acknowledged before me by Dennis W. Lancaster,
personal representative of the estate of Sybil W. Lancaster this 5'/11 day of October,
2006. '
WITNESS my hand and official seal.
BECKY BARBER - NOTARY PUBLIC
~" -
My Commission Expiree August 31,2010
Stat. 01
Wyominf
2
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