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AFFIDAVIT UNDER PENALTY OF PERJURY FOR RELEASE OF ACC I
OR PERSONAL PROPERTY WITHOUT COURT ADMINISTRATION
WYOMING STATUES SECTION 2 -1 -201 ET SEQ.
(FOR ESTATES WITH A TOTAL VALUE OF $200,000 OR LESS)
NOTICE TO BANK: MUST BE FILED WITH COUNTY CLERK AND BANK MUST RECEIVE A CERTIFIED COPY
PRIOR TO ANY DISTRIBUTION OF ASSETS.
I /We [Enter name(s)]
(individually
and jointly "Affiant whose address(es) is /are: (Attach additional sheets as needed)
declare to Bank of the West "Bank that the following is true and correct:
"Rob e r D f{�,
(the "decedent died in the City of
1. (Name of Deceased)
(Y\c C r 1
on (Date)
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.
County of Se H-- Lc. k e_, State of L..4
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 two hundred
thousand dollars ($200,000).
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)]: Parent(s); Spouse; 54 Child(ren);
Grandchild(ren); Sibling(s); Child(ren) of Sibling(s); Aunt(s)/Uncle(s); Heir(s) under will; Heir(s) at law;
Trustee of trust taking under a pour -over will; Other Describe:
There are no other distributees of the decedent having a right 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 Dollars
in the following accounts:
Branch Name City /State Account No. Amount
K m t/r4-Ar I -KQ vh►,, esr 1et1
(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)
Page 1 of 2
RECEIVED 8/5/2013 at 9:07 AM
RECEIVING 972445
BOOK: 817 PAGE: 174
JEANNE WAGNER
LINCOLN COUNTY CLERK, KEMMERER, WY
030 -05180 (Rev. 07/11)
Name and Address
Relationship to Decedent
Proportion Due Each Distributee
1) .Ja(A..
f
1 <e on hit er
5? f0
2)
i
3)
4)
01 75
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:
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 decedents 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 affirms or declares under penalty of perjury under the laws of the State of Wyoming that the foregoing is true and
correct.
This Affidavit is executed on 20 in the City of K.1N1 �1'I .ro
State of
MUS
On
appeared
W OwN N6-1
XECUTED BY ALL DISTRIBUTEES.
Signature Signature
Signature
STATE OF Mkt
COUNTY OF vim
personally
known to me (or proved to me on the basis of satisfactory 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 his /her /their authorized capacity(ies), and by his/her /their
signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
WITNESS my hand and offici seal.
Signature
Affidavit Small Estate Wyoming
Page 2 of 2
S ignature
20 (3 before me, the undersigned, a Notary Public in and for said State, personally
PAULA M BOWLING
-al) Notary Public
Lincoln County
Wyoming
My Commission Expires 1 •lit. iS 03
05180 (Rev. 07/11)