File No.
STATE OF NORTH CAROLINA
                                                                                                          In The General Court Of Justice
                                                County                                                          Superior Court Division
                                                                                                                Before The Clerk
        IN THE MATTER OF THE ESTATE OF:
Name Of Decedent
                                                                                      AFFIDAVIT OF NOTICE
                                                                                                       TO CREDITORS

                                                                                                                                       G.S. 28A-14-1, 28A-14-2
NOTE: The second option should be checked only in cases where the decedent had no outstanding debts, or the personal representative has paid in full 
all known debts. The first option should be checked in all other cases.
The undersigned affiant, being first duly sworn, says that:
 1.  Pursuant to G.S. 28A-14-1, I made a reasonable effort to as certain all persons, firms and corporations (including the Department 
     of Health and Human Services, Division of Medical Assistance, if at the time of the decedent’s death the decedent was receiving 
     Medicaid) having unsatisfied claims against the decedent and personally delivered or mailed a copy of the Notice to Creditors to all 
     such persons, firms and corporations then known to me, except for those claims that I recognize as valid.
 2.  No copy of the Notice to Creditors required by G.S. 28A-14-1 was mailed or personally delivered because, after making a 
     reasonable effort within the time provided by law, I am satisfied that there are no persons, firms or corporations (including the 
     Department of Health and Human Services, Division of Medical Assistance, if at the time of the decedent’s death the decedent was 
     receiving Medicaid) having unsatisfied claims against the decedent. (See note above.)
NOTE: Signature of only one affiant is necessary.
Date                                                                            Date

Signature Of Affiant                                                            Signature Of Co-affiant

     Personal Representative Or Collector                                            Personal Representative Or Collector
     Attorney For Personal Representative Or Collector                               Attorney For Personal Representative Or Collector

SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME                                      SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
Date                 Signature                                                  Date                   Signature

      Deputy CSC      Assistant CSC                     Clerk Of Superior Court       Deputy CSC           Assistant CSC               Clerk Of Superior Court
        Date My Commission Expires                                              Date My Commission Expires
 Notary                                                                                                                                   Notary
        County Where Notarized                                                  County Where Notarized
SEAL                                                                                                                                   SEAL

AOC-E-307, Rev. 2/15
© 2015 Administrative Office of the Courts