AFFIDAVIT OF RELATIONSHIP TO DECEDENT AND REQUEST FOR PAYMENT OF

DEPOSIT ACCOUNT TO FAMILY MEMBER PURSUANT TO 20 Pa.C.S.A. §3101

In re: Estate of Deceased	Date of Death:
COMMONWEALTH OF PENNSYLVANIA	)

) ss:

COUNTY OF LEHIGH	)

being duly sworn according to law, deposes and says that I am an adult individual and that

(Check and complete ONE of the following with preference given in the order named)

I am the surviving spouse of , having been married to him/her on

at
Date
City and State
- OR -

I am the adult child of ; the other adult children of are:

Name
Address (if deceased provide date of death)
- OR -

I am the parent of ; the other parent of is:

Name
Address (if deceased provide date of death)
- OR -

I am the adult sibling of ; the other adult siblings of are:

Name
Address (if deceased provide date of death)

In re: Estate of	Date of Death:	PAGE 2
Deceased

further states that the above facts are true and correct, and requests that pay any funds or benefits due and owing to the decedent at the time of their death pursuant to:

20 Pa.C.S.A. §3101 A B C D E,	a copy of which is attached to this Affidavit.

BY:
Date:
Signature
Print Name
Print Address

SWORN TO and subscribed before me

this ________ day of ___________, 20_____.

_____________________________________

Notary Public

Attachments:	Death Certificate

Photocopy of 20 Pa.C.S.A. §3101

Photocopy of receipt for payment of funeral bill

V E R I F I C A T I O N

I, _______________________________________________________________, hereby verify that the facts

name and relationship to decedent

set forth in the foregoing Affidavit of Relationship to Decedent are true and correct to the best of my knowledge, information and belief. I understand that false statements therein are subject to the penalties of 18 Pa. C.S.A. §4904 relating to unsworn falsification to authorities.

Date:	_____________________	_______________________________________________________

Signature

_______________________________________________________

Print Name

_______________________________________________________

Print Address

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IN THE COURT OF COMMON PLEAS OF LEHIGH COUNTY, PENNSYLVANIA

Rachel A Wotring

2012-08-15