(c) A document substantially in the following form may be used as the affidavit provided in subsection (b) of this section with the effect as prescribed in this section: THE COUNTY COMMISSION OF __________ COUNTY, WEST VIRGINIA
IN RE: THE ESTATE OF ______________________
DOD: _____________________
AFFIDAVIT FOR ANCILLARY ADMINISTRATION
OF WEST VIRGINIA REAL ESTATE
WITHOUT APPOINTMENT
(TESTATE)
STATE OF ________________ ,
COUNTY OF ______________ , to-wit:
I, ______________________________ , whose address is __________________ _________________________________________________________________ , being first duly sworn, upon oath and under penalty of perjury, do depose and say as follows:
1. The decedent, _____________________________ , died testate (with a will) on _____________________ (date of death), a resident of ___________ County, State of ____________________.
2. On ____________________ (date), the following person(s) was/were appointed as the personal representative of the Estate of ________________ by the ___________________ (name of foreign court), of ___________ (county), ________________ (state), being case number _______________ , if applicable: a. Name: ____________________________________________ Address: ____________________________________________________
b. Name: _____________________________________________________ Address: ____________________________________________________
3. An authenticated copy of the Last Will and Testament dated ____________ and the certificate of probate of such other state or jurisdiction is being furnished herewith for recording in this County.4. The Decedent died owning and possessing the following real estate situate in West Virginia: | Description | County | Assessed Value | Fair Market value |
a. | | | | |
b. | | | | |
c. | | | | |
d. | | | | |
| Total | | | |
5. Pursuant to the provisions of the Last Will and Testament of ___________________ , the decedent devised the aforesaid real estate to the following beneficiaries of the estate: a. Name: ____________________________________________________ Address: __________________________________________________
Relationship to Decedent: ____________________________________
Share or percentage: __________
b. Name: ____________________________________________________ Address: __________________________________________________
Relationship to Decedent: ____________________________________
Share or percentage: __________
c. Name: ____________________________________________________ Address: __________________________________________________
Relationship to Decedent: ____________________________________
Share or percentage: __________
d. Name: ____________________________________________________ Address: __________________________________________________
Relationship to Decedent: ____________________________________
Share or percentage: __________
6. The Estate of _______________ , the decedent, will be/has been fully administered by the domiciliary personal representative under the domiciliary proceedings in the other state or jurisdiction. No appointment of an ancillary personal representative to administer the decedent's real estate within the State of West Virginia is necessary for any proper purpose.7. I have personal knowledge of the above facts and am interested in the Estate of ____________________ , the decedent, as the ( ) acting domiciliary personal representative, ( ) surviving spouse, ( ) beneficiary under the decedent's will, ( ) heir at law, or ( ) other ______________________________ (describe relationship or interest). [Check one] ______________________________
Signature of Affiant
Taken, subscribed, and sworn to before me the undersigned authority by
_________________________________ , this day of , 20___.
{seal}
My Commission expires: ______________________________
__________________________________________________
Notary Public