Aff - Davis, Don E_4/14/1981l'hC afl idaoi.0 furnir.h�:d e;i�ouLd be tiinila: to Chr fo:lowfny,
$TA' !{ OF I:�:i�[AiLI
COU:tl'Y OP _��rJ BS a n/ 1 SS :
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, AFFIDAVI'C POR Ti�5NSP6R OF ASSIi'PS
IdITIiOU'C AD?II�75'fIL\TION o a�
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(rJ[� �• iC:/2G�c-aJ , being firsc dulv sworn upon ,_��c���,%� .f..��
oath deposes and says:
I.. 'i1inC ���°_"°='a,y,!_ �!.icd on S:I�c _oL/_._ J�ty iif
� 19�'% (te::ta�e), (in[esCaCC) whl.lc domi-
cLlcd in _�/_B_,LO� Coimty, T.ndi:mn.
2. 'Ihnr. no peti[.ion ior tl�e. nppointm�nt of a personal repre- , '
sentati.ve of his estatr_ is pending or has been granted.
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7iiat forty-five (451 days have elapsed since the death of
said dccedent.
Tne valuc o: the gross probate r.state l.ees ].lens and enciun-
b:�iices Chereon dpes not exceed f:i.ve thousnnd dollars ($5,000).
�. Thac this afPi.ant 1� a(t.�idow) (widower) (d:i.stribuCee) of
sai:l decedent and is enti.tled to recei��e w:i.tlinut adminis[ra-
� t.i.rnt thc fol.l.owing J.i.sced property f.rom [he p�:ix�n, finn or
c��rpor;iCion li.sL'ed nppo3l[c c:�id prop�:rty suUject to [hc
]t�:ns nnd encumbrnnces ch�ccon.
iveli•Ili A\D ADDR�SS OF
LIFN OR Pi{RSO\�, PIFN OR
KI?.il (1F Id}llii'.I: 1{VCl!*�SRANCI:S COP,PORATIOM1 HOLDI\C.
PR�+i'F.I;'C:' l,r)C,\TF.D VAl.lfl•: Ii� A\'1' P}:OPh:R1T OP D!iCF.DE6*L
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7'i�i., nCildn��ir. is m:idc for. thr. purposc of: i.nducing thc abovc named
holdc:s oE ti.tid dcrc;iciiC's Properr.y �o [urn s:rid prope�r[y ovc�r co N�is at-
tiiant ns �+r�,vi�i�d by ]nw. � _
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Subscribed �nd sworn to bef.ore me tl�is � dny of � 19��%�'�� �`. �•
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Notary Pub1d.E
Afy Corunission expires cS—�— �a