IN THE COURT OF COMMON PLEAS OF LEHIGH COUNTY, PENNSYLVANIA
AFFIDAVIT OF RELATIONSHIP TO DECEDENT AND REQUEST FOR PAYMENT OF
DEPOSIT ACCOUNT TO FAMILY MEMBER PURSUANT TO 20 Pa.C.S.A. §3101
|In re: Estate of Deceased |Date of Death: |
| | | |
COMMONWEALTH OF PENNSYLVANIA )
) ss:
COUNTY OF LEHIGH )
being duly sworn according to law, deposes and says that I am an adult individual and that
(Check and complete ONE of the following with preference given in the order named)
I am the surviving spouse of , having been married to him/her on
| |at | |
|Date | |City and State |
- OR -
I am the adult child of ; the other adult children of are:
|Name | |Address (if deceased provide date of death) |
| | | |
| | | |
| | | |
- OR -
I am the parent of ; the other parent of is:
|Name | |Address (if deceased provide date of death) |
| | | |
- OR -
I am the adult sibling of ; the other adult siblings of are:
|Name | |Address (if deceased provide date of death) |
| | | |
| | | |
| | | |
|In re: Estate of |Date of Death: PAGE 2 |
| | | |
|Deceased | | |
further states that the above facts are true and correct, and requests that pay any funds or benefits due and owing to the decedent at the time of their death pursuant to:
20 Pa.C.S.A. §3101 A B C D E, a copy of which is attached to this Affidavit.
|BY: | |Date: | |
| |Signature | | |
| | | | |
| |Print Name | |Print Address |
SWORN TO and subscribed before me
this ________ day of ___________, 20_____.
_____________________________________
Notary Public
Attachments: Death Certificate
Photocopy of 20 Pa.C.S.A. §3101
Photocopy of receipt for payment of funeral bill
V E R I F I C A T I O N
I, _______________________________________________________________, hereby verify that the facts
name and relationship to decedent
set forth in the foregoing Affidavit of Relationship to Decedent are true and correct to the best of my knowledge, information and belief. I understand that false statements therein are subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities.
Date: _____________________ _______________________________________________________
Signature
_______________________________________________________
Print Name
_______________________________________________________
Print Address
................
................
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