You are trying to collect from an estate that has a value of $100,000 or less. Things that are held jointly with someone else and assets that have a beneficiary (like life insurance) do not count toward the $100,000, AND
The person who died (the Decedent) passed away more than forty-five (45) days ago, AND
You understand that if someone else has rights to the same property, you have to pay them what they are owed, AND
You understand that any misrepresentation on this form is perjury and is punishable in court, AND
You understand that this form is not filed in court. After the form is completed, it is given to the entity (like the bank) that is holding the property.