TN 3 (08-89)

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 Numberholder2. Social Security Number
  
3. Name of Underpaid Beneficiary4. 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 fifty thousand dollars ($150,000);

  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.)

NAMERELATIONSHIPADDRESS
   
   
   

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