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AFFIDAVIT FOR DISTRIBlITION BY AFFIDAVIT AND SUMMARY
PROCEDURE PURSUANT TO WYOMING STATlITE § 2-1-201
THE STATE OF WYOMING
COUNTY OF L,~tcj~
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ó00792
AFFIDAVIT OF PQV1'\t~/.-J·t{rts«.iÚt"r -Jot'\~( (name of person signing affidavit)
ð-IYV~.r+~t Lf~fet- Ifu.ns'c~jt:e 1-
NameofDeceasedPersOlp LYI4V1 f'. H/,J4I'~t:ii~""f- .
I, 11.... m ...../t:.. M·_¥15.~ lcÉ'r -.. \t,:, H ~J' , being first duly sworn upon my oath, deposes
and states as follows:
i InQ ~'¡ht. ¿, A l!tbY!Sti/¿;¿¡--'
1. THat LY)lfH p. ¡'¡'lúY1.5.·~¡C-'r'~ . (name of deceased) died on the date of
LL~) ~þ27/f)9' I- '/9/D7 (Ly".,)
2. That I am the -..d I) ~ Gi kt~ r
': lY)aV+~ Li'+c\. I-Iw(\~li,t~,-
~ Lyltì^ ~ Htf,fl$tt/lY!r
3. That the vaJue of the estate, wherever located, less liens and encumbrances, of
t 't;f'ft.a. L~y.fÁ /ft¡,.J1j'qRt'r (the deceased) does not exceed $150,000.
, ;'n ~ i!LiJ1sCL!-:er ,_J L....'.l..i.. b, .
ff)a r7~ "ra rr'f.Ln.S~ F- ~r
4· That thirty (30) days have elapsed since the death of f 0 ' .
(name of deceased). Hf\ f. 1~'e:VI.~r
(relationship to deceased) of
(name of deceased).
5. That no application for appointment of a persona, I representatlye is J?~nding or
has been granted in any jurisdiction concerning .f!Jtl.r'f¡'1!( ¿ fr;1.. lfu/V'S.a.tvr'
(name of the deceased). ' LLfJII. ,\ p. Iikr\S.t¿?~r
6. That the claiming distributees that are entitled to payment or delivery of the
personal property ..of ~f'.¡.-ht L; c"/-ti !fu,n5kKflr (name of the deceased) are as
follows: ~ LyI'1f\ P 1f(¿'i1~aj:tJr
Name of Distributee
Relationship to Deceased
pome-!t,¡ Hu Y)Sattr-J0í1 ~S
A.Uf h I '(,r-(;frt~ sÝ--e~·_j
7. The above listed distributees are entitled to the payment and delivery of any and
all personal property including accounts held with any and all financial
institutions.
8. That pursuant to Wyoming Statute § 2-1-201, this affidavit has been filed with the
County Clerk, for and in the County of Lincoln, State of Wyoming.
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RECEIVED 8/8/2008 at 9:59 AM
RECEIVING # 941097
BOOK: 701 PAGE: 792
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
(;:06793
9. That pursuant to this affidavit and W.S. § 2-1-201, that the business and/or
financial institution of ~ t ALL &~,,~Ç/~naìi~tt:" ¡ns-}':~~eby directed to
pay toYct.V\'\ e (,... Hu y\q a lit'¡- - " )0/1 e-S (name of
distribute(s) to receive payment) any and all accounts held in the name of
.~ n1f.ir:f~... Lifa.. 1-/ti..i1$4-k~r (name of deceased).
t LY/1Y\ f HIA.r1J'e:..K'(r'"
10. Pursuant to W.S. § 2-1-201, upon presentation of this affidavit, any bank, savings
and loan institution, credit union, or any other like depository, held in the name
of the deceased, shall pay together with interest and dividends therein, to the
distributee or distributees as set forth in this affidavit.
DATED this £ day of A3 US-f d()()~
STATE OF WYOMING )
) ss.
COUNTYOFUNCOLN )
~e fo~e~ojng i~tru;ent was ~ckno:::iedged before ,:,e by '1.~V 0/ .
7 b/ll}¡ 'dJa....JA ~A thIS (7 day of &4:J 'ª" L
WITNESS my hand and official seal.
My commission expires: ~J :5, mf
NOT~1~
(_.
'~1&
~ é'
T^VLOR NOTARY PUBLIC
ANJI n'
. STATE OF
COUNTY NOF, WYOMING
LlNCOL
MY COMMISSION EXPIRES AUG 3. zoo¡
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