HomeMy WebLinkAbout906640IN THE DISTRICT COURT OF THE THIRD JUDICIAL DISTRICT
IN AND FOR THE COUNTY OF LINCOLN, STATE OF WYOMING
IN THE MATTER OF DETERMINATION OF HEIRSHIP OF
CARL BURTON JENSEN, Deceased.
Probate No.
AFFIDAVIT FOR COLLECTION OF CLAIM BY AFFIDAVIT
STATE OF WYOMING
COUNTY OF LINCOLN
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I, Gerald Lynn Boan, being first duly sworn, on oath depose and state as follows:
That I am over the age of twenty-one (21) years.
That I am an individual to whom the estate of Carl Burton Jensen would be indebted if the
estate were being administered upon.
That I became an individual to whom the estate of Carl Burton Jensen would be indebted if
the estate were being administered upon because I paid the funeral bill of Carl Burton Jensen
from Crandall Funeral Homes in the amount of $7,045.75 and the bill for his burial at the
South Lincoln Special Cemetery District in the amount of $150.00. The total indebtedness
I am hereby claiming is $7,195.75. I have received no payment on this debt on behalf o f the
estate of Carl Burton Jensen from any source.
That Carl Burton Jensen was my step-father who treated me as though I were his son. He
died on the 20th day of November, 2004 in the Town of Diamondville, County of Lincoln,
State of Wyoming.
That Carl Burton Jensen did not have a Will upon his death and accordingly died intestate
That the value of the entire estate of Carl Burton Jensen, wherever located, does not exceed
one hundred fifty thousand dollars ($150,000.00).
That ninety (90) days have elapsed since the date of the death of Carl Burton Jensen.
That no application for appointment of a personal representative is pending or has been
granted in any jurisdiction regarding Carl Burton Jensen.
To the best of my knowledge, no affidavit pursuant to § 2-1-201 W.S., in connection with
Carl Burton Jensen has been presented to any party referred to in § 2-1-201 W.S.
That by presentation of this affidavit I:
10.
ProbateXBoanL&ffidavit for Collection of Claim
RECEIVED. 2/23/2005 at 10:42 AM
RECEi;~ING # 906640
BOOK: 579 PAGE: 464
JEANNE WAGNER
~NCOLN COUNTY CLERK, KEMMER'ji~i j :~i
0465
11.
12.
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a. Hereby waive any immunities I have from suit or levy of execution I might otherwise
have;
b. Agree to indemnify and hold harmless from all claims whatsoever any party
delivering assets on the basis of such affidavit, to the extent of the fidl value of the
assets so delivered; and
c. Am answerable and accountable to a personal representative of the estate, if
appointed, or to any other person or party having a superior right.
That according to § 2-1-204(b) W.S., as a result of this affidavit having been duly filed with
the Lincoln County Clerk and a certified copy of that recorded affidavit being presented to
a party with custody of assets of Carl Burton Jensen, I am entitled to the payment or delivery
of all of those assets of Carl Burton Jensen subject to my potential obligation as set forth in
§ 2-1-204 (c) W.S.
That the personal property owned by Carl Burton Jensen is as follows:
a. Account #10032696 at 1st National Bank, Kemmerer, Wyoming.
b. Any insurance policy through Carpenters' and Millwrights' Benefit Fund.
That if any other property is located that is not identified above, I am entitled to that property.
Dated thi~'~_ ~' 2 -~X~ay of February, 2005.
STATE OF WYOMING
COUNTY OF LINCOLN
I, Gerald Lynn Boan, being first duly sworn, states that I am the affiant noted above in this
Affidavit for Distribution of Estate, that I have read the same, know the contents thereof, and that
the statements contained therein are true.
,,dd
Subscribed and sworn to by Gerald Lynn Boan before me this ..d.~ - ay of February, 2005.
NOTARY PUBLIC
My Commission Expires:
Probate'tBoan'tAffidavit for ColLection of Claim
STATE: OF., WYOMi:NG
:DEPARTMENT OF ~EAL~H.ii: ,:i ~
507 o,. ~=. I
/ - ~'* - uo.~q ~Z ~ January 22, 1922
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Residence - 15 Glenco street :: ~:::l:;:Di~mondville : [ Lineml~
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LOCAL FILE NUM~ER 1036A / CERTIFICATE OF DEATH STATE FILE NUMOER
This is a true and exact reprpduction of the document on file in the office of Vital
B?ord$ Se~.i .... (~h~yense. Wyoming.
;~.. :. ;opy iS not v~id u~Css prepared on