Aff - Wilson, Mary C_10/14/1983VO1. NO. 24%, Page 6 COUN'1'Y AUll1TUK5' CULLtII[v OCCOb2! 19tlZ
PAYMENT OF FUNDS DUE DECEASED PERSON, CUN'f1NUED
The affidavit furnished should be'similar to the followi�ng:
STATE OF'INDIANA ')
COUNTY G / Li SO/IJ )SS:
AFFIDAVIT FOR TRANSFER OF ASSETS '
LJITHOUT ADMINISTRATION
� �, being firs[ duly sworn upon �i
oach depos s nd says: '
1. ThatUSO�G�o-t, � di" ed on the � 9 day of • ��� 19 �-3
(cesta[e), (in[estate) while domiciled'in 2�� •!J ountY�
Indiana.
2. Tha[ no pe�i�ion for �he appoin�ment of a personal iepxesen-
cacive of his escate is pending or has been graci[ed.
3. Tha� forcy-five (45) days have elapsed since �he dea[h';of said
decedenc. .
4. The value of the gross probate esta[e less liens and eiicum-
.brances thereon does not exceed eight chousand five hundred�
dollars ($8,500). �
5. That [his affian[ is a(r:idov) (widower) (dis�ribu[ee) of said
decedent and is enciLled �o receive uichou[ administra[ion the
folloving lisced property from �he person, firm or corporation
Lisced opposite said property subjecc to [he liens and encum-
brances thereon.
KIND OF
PROPERTY
11H E RE
LOCATED VALUE
//f.bi
This affidavit is
holders of said decedent's
fiant as provided by law.
LZEN JR
EN CU*1BRAN C E S
IF ANY
NA."lE AI`D ADDRESS OF
PERSO�, FIRM OR
CORPORATIOiI HOLDING
PROP.RTY OF DECEDENT
A
made for [he purpose of inducing �he above named
property [o turn said pr.operty over to this af-
O-c.C. /3 �YP3
.
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��1�.� �° . `l-�� �
` A IANT '
�
_�070.� �-c�-�v �,
ADDRESS. ,�.-.: -- •
� .- 'p��
Subscribed and Sworn to before me this �day of D(��� =.�=taJQ_�?`�- _
� Notary Pu//b ' *.: �°.. =-�':;'.�
,/J ScLnq�Na. /1a-,/ ���'r�- ��'�
Coun[y of Residence �/�,.n t*.-.J l
My commission expires �-01 r-��
* Hav also be acknowledged bef.ore a clerk of the circuit court, or other officer
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