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AFFIDAVIT OF SURVIVORSHIP
00056:]
THIS AFFIDAVIT is made pursuant to W.S. § 2-1-201 by Robert M.
Zakotnik and Terry A. Zakotnik, who, being first duly sworn and upon their oath,
state as follows:
1. We are the sons of Helen K. Zakotnik who died intestate on April
24, 2006, in Kemmerer, Lincoln County, Wyoming.
2. At the time of her death Helen K. Zakotnik was a resident of Lincoln
County, Wyoming.
3.
We are the sole heirs and distributees of Helen K. Zakotnik, and
there are no other heirs or distributees having a right to succeed to
the property of Helen K. Zakotnik.
4.
The value of the entire estate of Helen K. Zakotnik, wherever
located, less liens and encumbrances, does not exceed One
hundred fifty thousand dollars ($150,000.00).
5.
Thirty (30) days have lapsed since the death of Helen K. Zakotnik.
6.
No application for appointment of a personal representative is
pending or has been granted in any jurisdiction.
7. As claiming distributees, we are entitled to payment or delivery of
any tangible personal property of Helen K. Zakotnik, including
deposits held by any bank, savings and loan institution, credit
union, asset management service, or like depository.
ROb~tL
~~nik
Page 1 of 3
STATE OF WYOMING )
) ss.
County of Lincoln )
0005r.~<jJ
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O"'...I";¡.e-") (,'0
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The undersigned ROBERT M. ZAKOTNIK, being first duly sworn,
states that he has read the foregoing Application and hereby affirms the
same as the truth, to the best of his knowledge and belief.
.-11::< ~.
Robert M. Zak~
ROBERT M. ZAKOTNIK, personally known to me did appear before
me and, upon being duly sworn, personally did sign the foregoing
document and verification thereof this (;¡/Jt~ day of O~f-CJ:XA"-
2006.
Witness my hand and official seal.
My Commission Expires: 11~/(P<i.O() 7
.;;'Ò~¿¡Y$~::3~j·'-~~>S;:'~~t.iÿ;:
[y StEifY A. Wemef . 't;':~;;:,:', . ~!~iiIfY Pt!!I.ro,~;i
'; County IJ~ i'~ Ii::;::: ' Slale of P
I~. Llncci1. . ., ..~: Wyoming ~~
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;!~ ComrrJÌ$¡:;¡\}n ¿..cp¡re« 11/1612007\1,.
,-. -' . ...... . '" ,(.
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Page 2 of 3
09253EO
STATE OF
)
) ss.
)
"1,G).O~ ,,.....-
IV ,"y ~ >1;) ~
County of
The undersigned TERRY A. ZAKOTNIK, being first duly sworn,
states that he has read the foregoing Application and hereby affirms the
same as the truth, to the best of his knowledge and belief.
TERRY A. ZAKOTNIK, personally known to me did appear before
me and, upon being duly sworn, personally did sign the foregoing
document and verification thereof this day of
2006.
Witness my hand and official seal.
~~ ~+J-ru~1PJ
Notary Public
My Commission Expires:
Page 3 of 3
Stale of (J al'¡,JJ¡ A1~
CoUntyOf~L,lJÅ S~ ~k
-
onf\~\}.Q.N¡,~~ ~q.ZDD~ before me, VI ,,-,an, '\ ~f'Clrun,- Ä:l(lliA
ÞI\II ., No.¡no..-lTllte CIt() ker IloCI.. 'JMeDoe. NGIaIy PuÞIIe-
personallyappe.ared \e H"''4 i\l\o, l\ Î.c. ~h\\c ,
\ N.tmII(o) of 1111*(1)
[J 138FeElRslly kR&\'!JR te me - OR - ~Ved to me on the basis of satisfactory evidence to be the perso~
whose namt$) isliA subscribed to the within Instrument and acknowledged to me that helaheJthey exeaJted
the same in hl~en't~8i~ authorized capacity,Oes), and that by hisJ~8rlt"eIr signatu~ on the instnJmsnt the
person.£8f, or thE. entity upon behalf of Which the perso~ acted, executed the instrument.
O~~Z53f~O
0005'16G
fœ "'=..61.'"
- Notary PublIc . CaIIfoInIa
RIvMIde CounIf
My Comm.....Octt'.
OPTIO l
Though thtJ dlJtø below 1$ not tequlfed by 1Bw. It m~ ptOv. VØlulIbItÞ to ptWOfJI relying on the cIocument 8nd oouJd pt8vent
frauduJtIV IBI1IOV8lIJ1Jd ~nt of this foIm to another rkxument.
Description of Attached Documont
Tiöe or Type of Document: ß J ju-;Iq lÚ..J tTf- SI J í )11 V/) rsÅ ;P
Document Date: ~t..1 j 'ky J Df, - !!J /'2-D/ of/}· Î:Yt.il I ~ Number of Pages; -3
I I I I
Signer(s)OtherT.'1anNamedAbove: II /4
I
Capaclty(iøs) Claimed by Slgner(s)
Signer's Name: '-¡:;Fry 4- 7 A- J¿J)J-{} / k.
~al
[J Corporate Offic.:er
Title(s):
o Partner - [J Limited [J General
[J Attorney-in-Fact
[J Trustee
[J Guardian or Conservator
[J Other:
Signer's Name:
D Individual
[J Corporate Officer
liUe(s);
[J Partner - [J Umited [J General
C Attorney-in-Fact
IJ Trustee
[J Guardian or Conservator
[J Other: Top O'tI'Iumb here
RIGHT THIJr,18PI{IN I
OF ~IÇNF:R
Signer Is Representing:
Signer Is Representing:
S0284CA(FI02I, "2000)
1994 NATIONALNOTARY ASSOCIATION-B23IIRafllIIMIAw.. ~,o. 8ox711M-CInasIe I"I1I1I. 0\ 1I13QØ.7184
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