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M
RECEIVED
LINCOLN COUNTY CLERK
KEMMEIAER, ?P-f'GMING
We, Russell J. Smith, Alysia J. Ricks, Lyndell C. Smith and Alayna K. Rigoulot, being
duly sworn under oath, state as follows:
1. Lynn Baker Smith (SSN: 528-10-4830) is the record owner of the Life Insurance
Policy with MONY, Policy No. 581-98-34
2. Lynn Baker Smith died on December 28, 1999. An Original copy of the death
certificate of Lynn Baker Smith is attached hereto.
3. The value of the entire estate does not exceed seventy thousand dollars ($70,000.00).
4. That thirty (30) days have elapsed since the death of the decedent.
5. That no application for appointment of a personal representative is pending or has been
granted.
6. We are the surviving children of Lynn Baker Smith.
7. We are the sole heirs of Lynn Baker Smith.
8. We hereby request that the insurance proceeds to the above-referenced policy be
distributed to us.
Dated this ;I day of April, 2001.
Ru9sell J.
' L- ,
L dell C. Smith
Alysia J. Ric
Alayna K. 9oulot
Affidavit For Distribution Page 1 of 2
STATE OF WYOMING )
SS.
COUNTY OF LINCOLN )
008
The foregoing instrument was acknowledged before me by Russell J. Smith, Lyndell C.
Smith and Alayna K. Riqoulot this 4: day of April, 2001.
Witness my hand and official seal.
OFFICIAL SEAL
KARA ROBINSON
Notary Public - Wyoming
County of Lincoln
(arty Commi:eton E>
- 13,2012
My Commission Expires:
STATE OF
COUNTY OF
SS
NOTARY PUBLIC
The foregoing instrument was acknowledged before me by Alysia J. Ricks this '7
day of April, 2001.
Witness my hand and official seal.
OFFICIAL SEAL
• KARA ROBINSON
Notar
y Public - Wyombg
County of Lin"
My Commission Expires:
NOTARY PUBLIC
Affidavit For Distribution Page 2 of 2