HomeMy WebLinkAbout967845AFFIDAVIT OF COLLECTION AND DISTRIBUTION OF
DECEDENT'S PERSONAL PROPERTY
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 myself as distributee, as
hereinafter set forth, and that I make the following statements in connection therewith:
1. That DONALD RAY SEVERNS, a/k/a DONALD R. SEVERNS died on or about
September 19, 2012, in Lincoln County, Wyoming, and was a resident of Lincoln
County, State of Wyoming, at the time of his death; that said decedent died intestate;
that I am the sole and only party entitled to the property of the decedent pursuant to
the laws of intestate succession in the State of Wyoming.
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 the surviving spouse of 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:
All death benefits payable under the Kemmerer Coal Co. Elkol-
Sorensen Mine Employer Pension Plan Contract #017368F
7. The undersigned requests that said death benefits be distributed to Susan M.
Fleischman.
1`i)
DATED this day of it/ 2012.
RECEIVED 11/8/2012 at 9:01 AM
RECEIVING 967845
BOOK: 797 PAGE: 679
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
USAN M. FT.RIS HMAN
00679
THE STATE OF WYOMING
ss.
COUNTY OF LINCOLN
The above and foregoing instrument was acknowledged before me this 0 day of
yk;1 2012, by SUSAN M. FLEISCHMAN.
WITNESS my hand and official seal.
My Commission Expires:
JAMIE PAINTER NOTARY PUBLIC
COUNTY OF
tF 1 STATE OF
LINCOLN WYOMING
My Commission Expires
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