HomeMy WebLinkAbout938921
000303
BANK.pIEWEST~.
AFFIDAVIT UNDER PENALTY OF PERJURY FOR RELEASE OF ACCOUNT
OR PERSONAL PROPERTY WITHOUT COURT ADMINISTRATION
WYOMING STATUES SECTION 2-1-201 ET SEQ.
(FOR ESTATIiS WITH A TOTAL VALUE OF 5150,000 OR LESS)
i
I
I
NOTICE TO BANK: MUST BE FILED WITH COUNTY CLERK AND BANK MUST RECEIVE A CERTIFIED COPY
PRIOR TO ANY DISTRIBUTION OF ASSETS. I
cVwe [Entername(s») c2a.'Íð(~ n F. I..f-u. L + ~ U "IS f :
and jointly "Affiant"), whose addressees) is/are: (Attach additional sheet1 as needed)
i
I
, (individually
I D 10 Cede{ Y" r+Ve.. .
)
8 3-10 I
declare to Bank of the West ("Bank'') that the following is true and correct: ,
1. (Name of Deceased) L cJ.. r r~ E, /-li{. J f.!J U', ~ f '
1:f-/?1 f111!.. r- ¿ r , County of L ì nLð I h
on (Date) IJp r< ( ,)., ;;LtJo,f
2. At least thirty (30) days have elapsed since the death of the decedent, as shown in a certified copy of the decedent's death
certificate attached to this affidavit.
(the "decedent") died in the City of
, State of WýDrh 1'Y"\j
3. No application for appointment of a personal representative is pending or has been granted in any jurisdiction.
4. The current value of the decedent's entire estate, wherever located, less liens and encumbrances, does not exceed one hundred
fifty thousand dollars ($150,000).
5. The claiming distributee(s) are entitled to payment or delivery of the property by virtue of the following facts concerning the
distributee's relationship to the decedent: Distributee(s) are: [Check appropriate box(es)): 0 Parent(s); iX1 Spouse; 0 Child(ren);
o Grandchild(ren); 0 Sibling(s); 0 Child(ren) of Sibling(s); 0 Aunt(s)fUncle(s); 0 Heir(s) under will; 0 Heir(s) at law;
o Trustee of trust taking under a pour-over will; 0 Other - Describe:
There are no other distributees of the decedent having a ríght to succeed to the property under probate proceedings.
6. At the time of the death of the decedent, the decedent was the owner of certain personal property held by Bank of the West, which
personal property is described as follows:
(a) Funds on deposit in the aggregate sum of CJ-'/I.V {jLtH..~veL. Dollars
DO
($ IjÓ¿)O-
) in the following accounts:
Branch Name
f)~ Mt?("é--r
K,~s:a.. uN
Account No.
Amount
Oð J-~ 305"¡(¿,
I, 660~
(b) Personal property situated in safe deposit box or vault no.
, or held in safekeeping at this branch; (Enter
Branch Name and State)
(c) The decedent's interest in: (Describe)
(continued)
Page 1 of2
RECEIVED 5/12/2008 at 11 :41 AM
RECEIVING # 938921
BOOK: 694 PAGE: 303
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
030-05180 (08/05)
000304
7. The affiant is entitled to payment or delivery of the described property, has the relationship described below and requests that the
described property be paid, delivered or transferred to affiant(s) directed as follows:
Name and Address
Relationship to Decedent Proportion Due Each Distributee
1)
2)
3)
4)
8. Affiant is the successor to the decedent's interest in the described property or is authorized to act on behalf of the successor of the
decedent with respect to the decedent's interest in the described property and no other person has a superior right to the interest of
the decedent in the described property.
9. If there is more than one affiant, all statements in this Affidavit are made individually and jointly.
10. In consideration for Bank's honoring this Affidavit, Affiant(s) agree(s) that Bank cannot be held liable for giving
Affiant(s) the money and/or property described in paragraph 6 and agree(s) to indemnify Bank and hold Bank harmless
against all liability, loss, costs, damages or expenses, including attorneys fees, which Bank may incur by reason of its
honoring this Affidavit. A receipt for the payment by each of the distributees shall constitute a valid and sufficient release and
discharge of Bank of the payment made.
11. Affiant represents and warrants that Affiant has been advised to consult with legal counsel prior to executing this
Affidavit and that Affiant has had the opportunity to consult with legal counsel and has obtained such legal guidance as
Affiant has deemed appropriate prior to executing this Affidavit.
12. Each affiant affinns or declares W1der penalty of perjury W1der the laws of the State of Wyoming that the foregoing is true and
correct.
This Affidavit is executed on (/11r? -y a ,20¿J,f'. in the City of ~~Æ/
State of j¡)r~
MUST BE EXECUTED BY ALL DISTRIBUTEES.
~JJkd~
Signature Þ Signature
Signature
Signature
STATE OF \"J ~ D ,,\,\ ., Y'\O¡
COUNTY OF l \ Y\L()\r-. J
On ('{\c\. ì . \ d .20 0 ~ . before me, the undersigned, a Notary Public in and for said State, personally
appeared C..6.:ro t~ f\ F t\ \Å n Çf¡ U t..s t personally
known to me (or prove(¡ to me on the basis ortiatisfactory evidence) to be the person(s) whose name(s)is/are subscribed to the within
instrument and acknowledged to me that he/she/they executed the same in hislher/their authorized capacity(ies), and by hislher/their
signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
WIlNESS
030-05180 (08/05)
Signature:
Affidavit - Small Estate W ming
Page 2 of2
Jl
~,~L~~~~'.'
stA rEi OFWY'OMING'"
/t':
"/DEPÀRTMEì'UQF fH::ÄLrH\:
.;.:
",
....
.. ..
..::........,.
·AdditionaID~ceaèht.ìbiör~ätibn{:',"'}
Place of BiiÌh:" :;Wihdbm,Mínnésòtå", ..,', ',,,
Residence: , Kemmerer, Wyoming ':" ,: ' , ','
Ma.rital StatI,Js:, ""Married ': '., . "', ". ' ,'. Name of Surviving Spouse: Carolyn F. Perala:. /
Arn,ed F9rces{;I'J()~' , )" ,",,;:'/,'" .' ",' '> ,',' ,..."" /
Na~e of Father:CaryrJ. HUltquiSl';;>:,<,/,
Malden Name of :Mother: Irene Ann Carlson,:;',,:,,' ,,'< \;
'Informant:' ') ,"}ÖarÖ Y¡'"F;Í1ultqglsf::..<\{":··" ,',
..
" DEA.TH'tERTIFICATE
.~ .~~.
.. . .
De'~edJnt:
Name:
, Gender:, ,
_,D~Je 6f Birth,:
Larry Edwin Hultquist
,Male" .','
¡iMaY14, 1947'
. . . . . . . .
'\/ St~te;FiI~ N¿rriber: ~oo8-ðo1b8~ ,",...'
....' Socii:!J$e~¡jr¡ty N.,u¡:nber: . __""
))\ge a~,.~~e l~~.~ otDeatp: 60 ý~.a'rs ,j
li1terval:
Minutes
"',","
I
I
I
~
I
I
I
,
,.."I,
.t. '
I
1
I
!'
"
¡
Dis~osition: "
~~~eogt~Ói~~~~t~3~~Y~ '," ,."·~~~dl~f~~f~,~~~~t~ii:;~..s~Jtþ",J~:r~ªn,,:lJ.+
, Funeral, Home or,Facj jty~ ';" , ., , ',,:';~:<,', . ,',':: '.,
Facility: ':::., ,Bait Farn!ly ~h~pel;,'Kemmerer, Wyoming
..... .....
I,
"
Certifier:
Näme: .,
Address: ,
....
, , ,,,Date FiI~d:,
,','
"
..
"