Estate Affidavit For Name/address Change Request printable pdf download

Estate Affidavit For Name/address Change Request

MINNESOTA SURETY AND TRUST COMPANY IN LIQUIDATION

ESTATE AFFIDAVIT for NAME/ADDRESS CHANGE REQUEST

After being duly sworn, the Affiant states as follows:

My name is _____________________________. I have personal knowledge of the matters set forth in this

affidavit, and if called to testify would do so as set forth herein.

I am ___ years of age.

My current address is ____________________________________________________________.

(*Insert deceased claimant’s name)

I am the sole beneficiary of the estate of *____________________________________________.

My relationship to *______________________________ is _________________________________.

I am the sole person who is entitled to any funds resulting from LCN# ________________

in the estate of Minnesota Surety and Trust Company.

I agree to allow my name and address to be provided to any subsequent claimants who come forward with

proof to claim entitlement to these funds.

I agree to hold harmless the Department of Commerce should subsequent claimants come forward with proof

to claim entitlement to these funds.

I swear or affirm that I am the claimant referenced in the mailing address on this form and/or am authorized to

sign this form on the claimant's behalf. I further swear under penalty of law that all information contained on this

form as well as all attachments are true and correct to the best of my knowledge.

___________________________________ _______________________________________________

(Affiant Signature)

(Affiant Printed Name)

State of __________ County of __________

Sworn to and subscribed to me by _____________ on this ____day of _______, 20___.

Notary Signature ____________________________

R6-13 (I) Name-Address Estate under 5000 Affidavit 8/2011

Estate Affidavit For Name/address Change Request