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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, Street Address, City, State, And Zip Code Of Decedent
AFFIDAVIT FOR COLLECTION OF
PERSONAL PROPERTY OF DECEDENT
(For Decedents Dying On Or Before Dec. 31, 2011)
INTESTATE TESTATE
County Of Domicile At Time Of Death
G.S. 28A-25-1; 28A-25-1.1
Date Of Death Date Of Will Place Of Death (if different from County Of Domicile)

Name, Street Address, PO Box, City, State And Zip Code Of Affiant 1 Name, Street Address, PO Box, City, State And Zip Code Of Affiant 2

Legal Residence (County, State) Legal Residence (County, State)

Name, Street Address, PO Box, City, State And Zip Code Of Attorney Attorney Bar No.

I, the undersigned affiant, being first duly sworn, say that:
1. I am an heir, an executor named in the will, a devisee named in the will, the public administrator,
a creditor of the decedent, and I am not disqualified under G.S. 28A-4-2.
2. At least thirty (30) days have passed since the date of the decedent’s death.
3. The decedent died intestate. testate.
4. (a) The decedent died on or before 9/30/09 and the value of all personal property owned by the decedent less liens and
encumbrances thereon, does not exceed $10,000.
(b) I am the surviving spouse and sole heir/devisee of the decedent, the decedent died on or before 9/30/09, and the value of
all personal property, less liens and encumbrances thereon, does not exceed $20,000.
(c) The decedent died on or after 10/1/09 and the value of all personal property owned by the decedent less liens and
encumbrances thereon, does not exceed $20,000.
(d) I am the surviving spouse and sole heir devisee of the decedent, the decedent died on or after 10/1/09, and the value of
all personal property, less liens and encumbrances thereon, does not exceed $30,000.
5. (Check if decedent died testate.) Decedent’s will dated as shown above has been probated in each county in which is located any
real property owned by the decedent as of the date of death; and a certified copy of the decedent’s will is attached to this Affidavit.
6. No application or petition for appointment of a personal representative is pending or has been granted in any jurisdiction.
7. After diligent inquiry, I have determined that the persons listed below are all the persons entitled to share in the decedent’s estate.
(If there is a court-appointed guardian for any such person(s), list the guardian’s name and address on an attachment.)
Name Age Relationship Mailing Address

Original - File Copy - Fiduciary Copy - Clerk mails copy to each person listed as entitled to share in the decedent’s estate
(Over)

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PRELIMINARY INVENTORY
(Give values as of date of decedent’s death. Continue on separate attachment if necessary.)
PART I.PROPERTY OF THE ESTATE
1. Accounts solely in the name of decedent (List bank, etc., account type, and balance. Do not list account nos.) Est. Market Value
$

2. Joint accounts without right of survivorship (List bank, etc., account type, balance, and joint owners. Do not list account nos.)
% Owned By Decedent
% Owned By Decedent
3. Stocks/bonds/securities solely in the name of decedent or jointly owned
without right of survivorship % Owned By Decedent
4. Cash and undeposited checks on hand
5. Household furnishings
6. Farm products, livestock, equipment, and tools
7. Vehicles (include or attach descriptions)

8. Interests in partnership or sole proprietor businesses
9. Insurance, Retirement Plans, IRAs, annuities, etc., payable to Estate
10. Notes, judgments, and other debts due decedent
11. Miscellaneous personal property
12. Real estate willed to the Estate $
13. Estimated annual income of Estate
(Base bond on this amount, if applicable.) TOTAL PART I. $
PART II. PROPERTY WHICH CAN BE ADDED TO ESTATE IF NEEDED TO PAY CLAIMS
1. Joint accounts with right of survivorship (List bank, etc., account type, balance, and joint owners. Do not list account nos.)
$

2. Stocks/bonds/securities registered in beneficiary form and immediately transferred on death or jointly
owned with right of survivorship
3. Other personal property recoverable (G.S. 28A-15-10)
4. Real estate owned by decedent and not listed elsewhere (attach description sufficient to identify each tract)
TOTAL PART II. $
PART III. OTHER PROPERTY
1. There is is not entireties real estate owned by decedent and spouse.
2. There are are not Insurance, Retirement Plans, IRAs, annuities, etc., payable to named
beneficiaries.
Signature Of Collector By Affidavit 1 Signature Of Collector By Affidavit 2

Name (type or print) Name (type or print)

SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
Date Signature Of Person Authorized To Administer Oaths Date Signature Of Person Authorized To Administer Oaths

Deputy CSC Assistant CSC Clerk Of Superior Court Deputy CSC Assistant CSC Clerk Of Superior Court
Date Commission Expires Date Commission Expires
Notary Notary
County Where Notarized County Where Notarized
SEAL SEAL
CERTIFICATION
I certify that the foregoing is a true and accurate copy as taken from and compared with the original on record in this office.
Date Signature
Deputy CSC Assistant CSC Clerk Of Superior Court SEAL
NOTE: This Affidavit For Collection Of Personal Property Of Decedent authorizes the named collector by affidavit to receive and administer ALL of the
personal property belonging to the named decedent pursuant to G.S. Chapter 28A, Article 25.
AOC-E-203A, Side Two, Rev. 8/21, © 2021 Administrative Office of the Courts

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