STATE OF SOUTH CAROLINA	)	IN THE PROBATE COURT
)
COUNTY OF GREENVILLE	)
)	AFFIDAVIT FOR COLLECTION OF PERSONAL PROPERTY
IN THE MATTER OF:	)	PURSUANT TO SMALL ESTATE PROCEEDING
)
(Decedent)	)	CASE NUMBER: __________________

INTESTATE (NO WILL)

TESTATE (SEE INFORMAL ORDER OF PROBATE)

The undersigned states as follows:

1.	Decedent’s Information:
Full Legal Name (include all known names):
Date of Birth:
Date of Death:
Age at date of Death:

2.	Decedent was domiciled in this county at date of death:

Address: _________________________________________________; County: Greenville; State: South Carolina.

Decedent was not domiciled in South Carolina, but probate property of Decedent was located in this county at

date of death at: Address: ___________________________________: County: Greenville; State: South Carolina.

If the above address is the address of a nursing home, a prison, or other residential facility, please give the last address of the Decedent prior to entering the facility: ________________________________________________________________

_________________________________________________________________________________________________

3. More than thirty (30) days have passed since the Decedent’s death.

4. No Application or Petition for the appointment of a Personal Representative is pending or has been granted in any jurisdiction.

5. This affidavit is pursuant to SCPC 62-3-1201. The successor(s) named herein is/are entitled to the payment of any sums of money due and owing to the Decedent, and to the delivery of all probate tangible personal property belonging to the Decedent and in the possession of another, and to the delivery of all instruments evidencing a debt, obligation, stock, or chose in action belonging to the Decedent in the following proportions. Names and addresses of the Decedent’s successors (Example: heirs or devisees) are:

Name of Successor*	Year of Birth	Address	Relationship	Percentage Interest/ Amount

See attached sheets for additional successors (check, if applicable).

(*For this purpose, successors include any individual(s) who has/have paid reasonable funeral expenses; attach detailed proof of payment.)

FORM #420ES (4/2017)

62-3-1201, 62-3-1202	PAGE 1 of 3

6.	The value of the entire probate estate wherever located, less liens and encumbrances, does not exceed Twenty-Five Thousand Dollars ($25,000.00) and does not include any interest in real property as indicated below:

Bank Account(s):	$	Bank Name:	Type of Account:
$	Bank Name:	Type of Account:
Stock(s):	$	Company Name:	# of Shares:
$	Company Name:	# of Shares:
Motor Vehicle(s):	$	Year/Make/Model:	VIN:
$	Year/Make/Model:	VIN:
$	Year/Make/Model:	VIN:
$	Year/Make/Model:	VIN:
Mobile Home:	$	Year/Make/Model:	VIN:
$	Year/Make/Model:	VIN:
Boat/Motor/Trailer:	$	Year/Make/Model:	VIN /Serial #:
$	Year/Make/Model:	VIN /Serial #:
Unclaimed Property:	$	From:	ID #:
$	From:	ID #:
Life Insurance	$	Company Name:	Policy #:
(payable to estate)	$	Company Name:	Policy #:
Other:	$	Refund:
$
$

TOTAL VALUE: $____________

LIENS/ENCUMBRANCES against above assets (attach proof of encumbrances):

$____________	Lienholder: _______________________________________________________

$____________	Lienholder: _______________________________________________________

TOTAL LIENS:	$____________

NET:	$____________

See attached sheets for additional assets / encumbrances (check, if applicable).

VERIFICATION

The undersigned, being sworn, states: That the facts set forth in the foregoing statements are true to the best of the undersigned's knowledge, information and belief; and the undersigned hereby submits to the Court's jurisdiction in this matter.

SWORN to before me this	day of	Signature:
, 20	Print Name:
Address:
Notary Public for South Carolina	Telephone (Work):
My Commission Expires:	(Home):
(Cell):
E-mail:
Relationship to Decedent/Estate:

COURT USE ONLY Received: _______________________________ $________ Court Cost Paid ________ JA: _____

FORM #420ES (4/2017)	PAGE 2 of 3