Analyst initials PROOF OF DEATH AND HEIRSHIP (FILL IN ALL BLANKS) STATE OF COUNTY OF , address: of lawful age, being first duly sworn according to law, on oath says: That the statements hereinafter set forth, including answers to questions propounded, constitute a true, correct and complete statement of the family history of the person hereinafter named as “decedent” and of the estate of such decedent. Name of Decedent Date decedent died Where? Did decedent leave a will? If so, has same been probated? Or has other administration proceedings been had on decedent’s estate? If so, when? Where? Were there any unpaid debts or obligations due by decedent at the time of death? If so, give the following information: To Whom Owing Amount Nature of Debt Paid-Unpaid now Was decedent surety on any bond at the time of his death? Were there any suits pending, or any judgments rendered in any court, against decedent at the time of death? If so, state briefly the nature, amount involved and parties to the action: Were decedent's minerals inherited? If no, date minerals were acquired: Was decedent single, married, divorced or widowed at time of death? If married, to whom? Date of marriage: Was decedent ever married to any other than above-named person? If so, give the following information: (List names in order of marriage) Name/Address of Spouse Living or Dead Divorced Date of Death or Divorce If decedent had any children by any person, or adopted any children, give the following information: By Which Name of Child Age Address LivingDate Death Person Dead If a deceased child left descendants, give the following information: ___________________ Name of deceased child Name of Child Age Address LivingDead Date of Death LivingDead Date of Death Spouse/Address: ___________________ Name of deceased child Name of Child Age Address Spouse/Address: In case decedent left no children or descendants of deceased children, then please furnish the following information: Name of Parents Address Living-Dead Date of Death Father Mother Give names of brothers and sisters of decedent: Name Relation LivingDead Address Date of Death Give names of children of deceased brother or sister: Name of Child Child of Age Address LivingDead Legal description of the property owned by the deceased (include Section, Township, Range and County(ies) and State: _______________________________________________________________________________ ________________________________________________________________________________________ Here briefly state facts and circumstances (such as being a relative of, or attorney or agent for, deceased) which will show basis and source of information hereinbefore given: Affiant Subscribed and sworn to before me this day of month 20___. NOTARY PUBLIC My commission expires: SUPPORTING AFFIDAVIT STATE OF COUNTY OF , of lawful age, being first duly sworn, on oath states: That this affiant was well and personally acquainted with in lifetime (being the person described as “decedent” in the Proof hereinabove set forth); that this affiant has read the foregoing Proof of Death and Heirship, knows the contents thereof, and that each and every statement therein contained is true, to the best of affiant’s knowledge and belief. Affiant Subscribed and sworn to before me this day of , 20___. NOTARY PUBLIC My commission expires: AffidavitofHeirship.doc INSTRUCTIONS FOR COMPLETING PROOF OF DEATH AND HEIRSHIP AFFIDAVIT 1. This form should be completed by someone other than an heir, who is familiar with the family history of the decedent, and who will obtain no benefit from the Estate. 2. The person completing the form should read it carefully and answer the questions that are applicable, paying particular attention to the name(s) and address(es) of the heir(s), then sign in the first space provided for “Affiant” before a Notary Public. 3. A second person familiar with the Estate should complete and sign the Supporting Affidavit before a Notary Public. 4. Completed, fully executed and notarized Affidavit should be recorded in ___________ County, ____________ The address is: County Clerk County, State address city, state phone # 5. – call for the recording Fee A recorded copy should be sent to Anadarko E&P Onshore LLC in the enclosed envelope.
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