Date:
Place of execution: , State of , County
I, (hereinafter referred to as the "Affiant"), residing at , being of legal age, hereby declare and acknowledge as follows:
I swear and affirm under penalty of perjury that the information and facts outlined in this statement, to the best of my knowledge, are true and accurate.
Annex. A certified copy of the certificate of death of .
Affiant's signature: _______________________
Notary Acknowledgment
Sworn to and subscribed before me on
__________________________
(Notary public's name and seal)