1. I am the successor of _________________________________________ who died on
   
   _________________________________________. I am the successor by reason of the fact that
   
   _________________________________________________________________________________.
   
   
2. The value of the entire estate of the decedent, wherever located, less liens and encumbrances, does not exceed $15,000.
   
   
3. Thirty days have lapsed since the death of the decedent.
   
   
4. No application or petition for the appointment of a personal representative of the decedent's estate is pending or has been granted in any jurisdiction.
   
   
5. I, as successor of the decedent, am entitled to the payment of any sums of money due and owing the decedent and to the delivery of all tangible personal property belonging to the decedent and to the delivery of all instruments evidencing a debt, obligation, stock or chose in action belonging to the decedent.
   
   

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Signature

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Mailing Address

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City, State ZIP

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Telephone