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IN THE COUNTY COMMISSION OF WOOD COUNTY, WEST VIRGINIA

RE: THE ESTATE OF _____________________________

DOD: ______________________

AFFIDAVIT FOR SMALL ESTATE

1. My name is _______________________________, and my current address is

_______________________________________________________________________

______________________________________________________________________.

2. The Decedent, ____________________________________________, died on

_____________________________, as a resident of ____________________ County,

State of West Virginia, with his/her usual residence being _________________________

______________________________________________________________________.

TESTATE (with a Will) _____ (if “yes” complete Paragraph 4) or

INTESTATE (without a Will) _____ (if “yes” complete Paragraph 5);

In either case, now proceed to Paragraph 6.

4. If TESTATE:

At the date of death, the Decedent died with an original Last Will and Testament of the

Decedent dated ____________________________, without any codicil thereto ( ) or

with codicil(s) thereto dated ___________________( ) {Check if applies}. The aforesaid

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original Last Will and Testament of the decedent, together with any codicil(s), is furnished

herewith for recording in this County as permitted by West Virginia §44-1A-2(b).

Under the Last Will and Testament of the Decedent, the following person(s) is/are

nominated to be the personal representative(s) of the Estate:

_______________________________________________________

________________________________________________________

Pursuant to the provisions of the above referenced Will of the Decedent, the

following person(s) is/are the named beneficiaries of the estate of the Decedent:

a. NAME:___________________________________________________

ADDRESS:________________________________________________

________________________________________________________

________________________________________________________

RELATIONSHIP to Decedent: ________________________________

________________________________________________________

________________________________________________________

RELATIONSHIP to Decedent: ________________________________

Share or percentage or particular item(s): ______________________

________________________________________________________

________________________________________________________

c. NAME:___________________________________________________

ADDRESS:________________________________________________

________________________________________________________

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Share or percentage or particular item(s): ______________________

________________________________________________________

________________________________________________________

d. NAME:___________________________________________________

________________________________________________________

e. NAME:___________________________________________________

ADDRESS:________________________________________________

________________________________________________________

________________________________________________________

RELATIONSHIP to Decedent: ________________________________

Share or percentage or particular item(s): ______________________

________________________________________________________

________________________________________________________

Share or percentage or particular item(s): ______________________

________________________________________________________

________________________________________________________

g. NAME:___________________________________________________

ADDRESS:________________________________________________

________________________________________________________

________________________________________________________

RELATIONSHIP to Decedent: ________________________________

Share or percentage or particular item(s): ______________________

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5. If INTESTATE

At the date of death, the Decedent died intestate with no known Will. The Decedent lest

as his/her heirs-at-law and distributes in accordance with the laws of intestate descent

and distribution of the State of West Virginia, the following persons:

b. NAME:___________________________________________________

ADDRESS:________________________________________________

________________________________________________________

________________________________________________________

RELATIONSHIP to Decedent: ________________________________

Share or percentage: ______________________________________

c. NAME:___________________________________________________

ADDRESS:________________________________________________

ADDRESS:________________________________________________

________________________________________________________

________________________________________________________

RELATIONSHIP to Decedent: ________________________________

Share or percentage: ______________________________________

e. NAME:___________________________________________________

ADDRESS:________________________________________________

________________________________________________________

________________________________________________________

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f. NAME:___________________________________________________

ADDRESS:________________________________________________

________________________________________________________

________________________________________________________

RELATIONSHIP to Decedent: ________________________________

RELATIONSHIP to Decedent: ________________________________

Share or percentage: ______________________________________

6. The Decedent’s entire personal probate estate, as of the date of the Decedent’s

death, wherever located, consists only of small assets and the aggregate fair market

value of the small assets does not exceed $50,000. The small assets of the Decedent are

described and itemized as follows:

DESCRIPTION FAIR

6. _________________________________________________________________

7. _________________________________________________________________

8. _________________________________________________________________

9. _________________________________________________________________

10. _________________________________________________________________

(IF MORE SPACE IS NEEDED, attach additional pages to affidavit)

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7. The Decedent did ( ) / did NOT ( ) {Check one which applies} die seized

and possessed of any probate real estate or interests in probate real property in the

State of West Virginia. If the Decedent died seized and possessed of any probate real

estate or interest in real estate in the State of West Virginia, the aggregate fair market

value of all of the real estate interests in real property situate in the State does not exceed

2.___________________________________________________________________

3.___________________________________________________________________

10.__________________________________________________________________

(IF MORE SPACE IS NEEDED, attach additional pages to affidavit)

8. ( ) {Check if applies} or ( ) {Check if Not Applicable}. If the affiant is a

Successor who was nominated as a personal representative or executor under the

provisions of the above Will of the Decedent, at least 30 days have elapsed since the

Decedent’s date of death and no application for the appointment of a personal

representative for the Decedent is pending or has been granted in any jurisdiction.

of the above Will of the Decedent or if the Decedent died intestate without a Will, at least

60 days have elapsed since the Decedent’s date of death and no application for the

appointment of a personal representative for the Decedent is pending or has been

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granted in any jurisdiction, and no affidavit of Small Estate has been filed by a Successor

nominated as a personal representative or executor under the provisions of the Will of

the Decedent.

________________________________

Signature of Affiant/Successor

Taken, subscribed and sworn to before me the undersigned authority by

_________________________________, this _____ day of _______________, 20____.

________________________________