Affidavit for Collection of Personal Property
       Mail to:  Arizona Department of Revenue  •  Unclaimed Property Unit  •  PO Box 29026  •  Phoenix, AZ  85038

  1  Please print or type your answers to each question:
 1a. Name of Decedent                                                                                     1b. Date of Death

                                                                                                               m m D D y y y y
 1c. Name of Decedent’s Spouse                                                                            1d. Spouse’s Date of Death
                                                                                                               (if now decreased) 

                                                                             Not married at time of death     m m D D y    y     y y
                                Attach the decedent’s death certificate to this affidavit.

 2   An answer for each question in Section 2 is required.  Carefully read the instructions for questions answered, “Yes”.
 2a. Did the decedent have a valid will as defined by                        No  If “yes”, attach a complete copy of the valid will and trust 
     A.R.S. §§14-2501 to 2517?                                                    if one is mentioned in the will.  Payment will be issued per 
                                                                             Yes the terms of the will/trust.
 2b. Is an application for appointment of personal representative pending,   No  If “yes”, only the assigned personal representative may 
     or has a personal representative been appointed?                             claim.  Attach a copy of your Letters of Office certified 
                                                                             Yes within 60 days.
 2c. Was the value of all personal property in the decedent’s estate,        No  If “yes”, the State of Arizona requires probate for this estate.  
     wherever located, less liens and encumbrances, valued above                  Attach the certified Decree of Distribution for a closed 
     $75,000 at the date of death or date of affidavit, pursuant to          Yes estate or, once probate has been initiated, the personal 
     A.R.S. §§14-3971(B)(2) to 14-3971(B)(2)(b)?                                  representative may claim; see 2b.

 3   Choose one option in Section 3, and provide the requested information:
       As a rightful heir of the decedent, I am claiming the payment of the decedent’s personal property held by the Arizona Department of 
 3a.  Revenue’s Unclaimed Property Unit that I am entitled to because of my relationship to the decedent of:
       Your relationship to the decedent 
       I hereby unconditionally and irrevocably assign, grant, and transfer all rights, title, interest, and obligation in all unclaimed property held by 
 3b.  the Arizona Department of Revenue’s Unclaimed Property Unit in the name of the decedent to:
       Name of heir you are assigning to 
Each heir that wishes to assign their rights must fully complete this affidavit, choose option 3b, and name the heir they wish to 
assign rights to.  The heir accepting payment must file a claim and provide supporting evidence including their own affidavit.

 4   Please print or type your answers to each question:
 4a. Name of Decedent’s Descendants (children, grandchildren, etc.)    4b. Relationship      4c. Relationship       4d. Date of Death
      Decedent had no children                                             to Decedent           to you            (if now deceased)

                        To list more than six descendants, attach a page showing additional names. 
                                                      Form must be signed and notarized.
                                                 !
ADOR 10695 (1/14)                                                                                                                 Page 1 of 2 
Previous ADOR 17-5509

     YOU MUST LIST BELOW ANY ADDITIONAL HEIRS AS DEFINED BY A.R.S. §§14-2102-14-2106.

 5   If the decedent was not survived by a spouse or descendants, provide the following parent information:
 5a. Name of Decedent’s Father                                         5b. Father’s Date of Death (if now decreased)
                                                                           m m D D y y y y
 5c. Name of Decedent’s mother                                         5d. mother’s Date of Death (if now decreased)
                                                                           m m D D y y y y

     If the decedent was not survived by any family member previously listed, list in Section 6 the decedent’s parents’ 
 6   descendants (siblings, nieces, nephews):
     6a. Name of Decedent’s Parents’ Descendants                     6b. Relationship  6c. Relationship               6d. Date of Death
                     (children, grandchildren, etc.)                    to Decedent         to you                    (if now deceased)

                     To list more than four decedent’s parents’ descendants, attach a page showing additional names. 

 7   If the decedent was not survived by any family member previously listed, provide the following information:
 7a. Decedent’s Paternal Grandfather                Date of Death      7b. Decedent’s maternal Grandfather         Date of Death
                                                     m m D D y y y y                                          m m D D y y y y
 7c. Decedent’s Paternal Grandmother                Date of Death      7d. Decedent’s maternal Grandmother         Date of Death
                                                     m m D D y y y y                                          m m D D y y y y

     If the decedent was not survived by any family member previously listed, list in Section 8 the decedent’s grandparents’ 
 8   descendants (aunts, uncles, cousins):
     8a. Name of Decedent’s Grandparents’ Descendants                8b. Relationship  8c. Relationship               8d. Date of Death
                     (children, grandchildren, etc.)                    to Decedent         to you                    (if now deceased)

           To list more than four decedent’s grandparents’ descendants, attach a page showing additional names.

 I swear and attest that all claims, assertions and signatures made in this affidavit are true and material, and I acknowledge that any false 
 statement in this affidavit may subject me to penalties related to perjury and the subornation of perjury.

 Signature                                                                                
                                                                                      Date 

STATE OF                                                           )
COUNTy OF                                                          )

Subscribed and sworn before me this ____ day of _____________________,                      (Notary Seal)
20____, by:

PRINT NAME OF SIGNOR                                                     NOTARY PUBLIC
ADOR 10695 (1/14)                                                                                                                 Page 2 of 2 
Previous ADOR 17-5509