HomeMy WebLinkAbout965275AFFIDAVIT OF COLLECTION AND DISTRIBUTION OF
DECEDENT'S PERSONAL PROPERTY
00317
The undersigned, being first duly sworn, on oath deposes and states that I am making this
affidavit pursuant to Section 2 -1 -201, W.S.A. (2011), on behalf of the Donald G. Larson Revocable
Trust u/a March 4, 2003 (the "Trust as distributee, as hereinafter set forth, and that I make the
following statements in connection therewith:
1. That DONALD G. LARSON, died on February 19, 2012, in Salt Lake County, Utah,
and was a resident of Lincoln County, State of Wyoming, at the time of his death;
that said decedent died testate; that the Trust is the sole and only party entitled to the
hereafter mentioned property of the decedent pursuant to his Last Will and Testament
dated November 26, 2007.
2. That the value of the entire estate, wherever located, less liens and encumbrances,
does not exceed Two Hundred Thousand Dollars ($200,000.00).
3. That more than thirty (30) days have elapsed since the date of death of the decedent.
4. That no application for the appointment of a personal representative is pending or has
been granted in any jurisdiction in this state.
5. That the claiming distributee is entitled to payment or delivery of the property
described below; that the distributee is a trust established by the decedent; and that
there are no other distributees of the decedent having a right to succeed to the
property under probate proceedings.
6. That the property that is the subject of this Affidavit is described as follows:
(a) Ability Insurance check for the amount of $743.03
(b) United HealthCare Services Inc. check in the amount of $25.05
7. The undersigned requests that the above mentioned checks be deposited to an account
established for the Donald G. Larson Revocable Trust u/a March 4, 2003.
DATED this day of
RECEIVED 6/26/2012 at 12:15 PM
RECEIVING 965275
BOOK: 788 PAGE: 318
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
2012.
BONNIE R. LARSON, as Successor Trustee of
the Donald G. Larson Revocable Trust u/a
March 4, 2003
STATE OF WYOMING
COUNTY OF L+ n Col l r1
My Commission Expires
as -I Cp
ss.
The above and foregoing instrument was acknowledged before me this day of
(kr\ C 2012, by BONNIE R. LARSON, as Successor Trustee of the Donald G. Larson
Revocable Trust u/a May 4, 2003.
WITNESS my hand and official seal.
2
JOSELYN M. HARMON
Notary Public
Lincoln County
Wyoming
My Commission Expires 1 1 5 -1'
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