TN 19 (10-20)
GN 02315.200 Affidavit Showing Right to Receive Money Under Section 13100 of the California Probate
Code - Exhibit
AFFIDAVIT SHOWING RIGHT TO RECEIVE MONEY UNDER
SECTION 13100 OF THE CALIFORNIA PROBATE CODE - Exhibit
1. Name of Numberholder |
2. Social Security Number |
|
|
3. Name of Underpaid Beneficiary |
4. Place of Death |
|
|
The undersigned declares that he or she is the surviving (Relationship to Decedent) of (Name of Deceased Person Listed in 3 Above) , who died on (Month, Day, Year) domiciled in the State of California, and that:
-
(1)
At least 40 days have elapsed since the death of the decedent, as shown in the certified
copy of the decedent's death certificate attached to this affidavit or declaration;
-
(2)
No proceeding is now being or has been conducted in California for administration
of the decedent's estate;
-
(3)
The gross value of the decedent's real and personal property in California does not
exceed one hundred sixty-six thousand two hundred fifty dollars ($166,250);
-
(4)
The property to be paid to the affiant consists of unpaid Social Security benefits;
-
(5)
No person who is not named on this affidavit has a right to succeed to the decedent's
property;
-
(6)
The affiant is either (A) the successor of the decedent, or (B) authorized to act
on behalf of the successor of the decedent, with respect to the decedent's interest
in the described Property. "Successor of the decedent" means: (a) If the decedent
died leaving a will, the affiant is the sole beneficiary or one of the beneficiaries
who succeeded to property under the will. (b) If the decedent died without a will,
the affiant is the sole person or one of the persons who succeed to the property of
the decedent based on relationship to the decedent.
Did the decedent leave a will? Yes No
If the decedent left a will, list below all beneficiaries of the will. If there is
no will, list the decedent's surviving relatives. (List yourself first.)
NAME |
RELATIONSHIP |
ADDRESS |
|
|
|
|
|
|
|
|
|
LIST ADDITIONAL NAMES ON THE REVERSE SIDE IF NECESSARY
-
I request, pursuant to the provisions of section 13100 of the California Probate Code,
that the Social Security Administration pay me the underpayment due the decedent or
his estate under the Social Security Act.
I affirm or declare under penalty of perjury under the laws of the State of California
that the foregoing is true and correct.
|
Signature of Affiant |
Date |
|
|
Address Place of Execution |