STATE OF ISRAEL SMALL ESTATE AFFIDAVIT AND INDEMNITY

FORM RESET
STATE OF ISRAEL SMALL ESTATE AFFIDAVIT AND INDEMNITY FORM
THIS FORM MAY ONLY BE USED IF:
1. The face amount of the decedent’s bond does not exceed $6,000. 2. There has been no administration of the estate.
We, the undersigned, being severally duly sworn, depose and say that A) None of the following persons has been declared legally incompetent by
any court, or has a representative, committee, or guardian appointed to represent his or her affairs; B) The funeral expenses and all debts due
and owing by the decedent at the time of death have been paid; C) No letters of Administration or Letters Testamentary have been issued by a
court and no petition for the appointment of any personal representative or the issuance of any letters is pending in any court; nor do any of the
undersigned intend to file such petition or know of any intention on the part of anyone else to file such petition.
D)
E)
We are fully familiar with the facts relating to the estate of ____________________________________________________
who died intestate or leaving a Will (attach a fully executed copy). We will attach certified copy of the death certificate showing that death
occurred on or about ___________________________.
At the time of death, the decedent was a resident of the State of __________________________
residing at ________________________________________________________________________________.
F)
G)
The assets of the estate of the decedent do not exceed $____________________.
We are the only surviving heirs in law and next of kin and beneficiaries under the will of the decedent who are entitled to share in the estate
and our respective relationships to the decedent and our addresses are as follows. All heirs at law and next of kin must be listed. None may
be omitted:
NAME
RELATIONSHIP TO DECEDENT
RESIDENCE
___________________________
________________________
______________________________________________
___________________________
________________________
______________________________________________
___________________________
________________________
______________________________________________
___________________________
________________________
______________________________________________
___________________________
________________________
______________________________________________
___________________________
________________________ ______________________________________________
The undersigned make this affidavit for the purpose of inducing the State of Israel, through Computershare Trust Company, N.A., fiscal agent
to:
(Check one box as applicable)
Name: ________________________________________________________________
H)
Transfer and Re-Register in the name of
OR
Pay the maturity value to
TYPE OF BOND
(Savings, Coupon, Current Income)
I)
Address: ______________________________________________________________
Social Security Number: __________________________________________________
ISSUE/PRINCIPAL
AMOUNT
BOND# (Bond Certificate)
OR
ACCOUNT # (Book Entry)
NAME OF ISSUE:
(i.e., 6th IVRI, Jubilee 3rd Series)
The undersigned jointly and severally agree to indemnify and hold harmless the State of Israel, Computershare Trust Company, N.A. as Fiscal
Agent, and Development Corporation of Israel, their successors and assigns from and against any and all liability, loss, and damage or
expense in connection with or arising out of this transfer, purchase, or redemption. All heirs and next of kin must sign here. If any one of
them is a minor, the parent may sign on behalf of the minor. Each and every signature in the following section must be notarized.
____________________________________________________ L.S.
____________________________________________________ L.S.
____________________________________________________ L.S.
____________________________________________________ L.S.
____________________________________________________ L.S.
____________________________________________________ L.S.
On this _____________ day of _____________________, before me personally appeared __________________________________________________
to me known and known to me to be the person(s) described in and who executed the foregoing instrument, and they thereupon acknowledge to me
that they executed the same.
STATE OF __________________________
COUNTY OF_________________________