United States of America

State of West Virginia County of Harrison, ss:

Affidavit for Ancillary Administration

Of West Virginia Real Estate

without Appointment

Testate

STATE OF ______

COUNTY OF ______

I, ______, whose address is ______, being first duly sworn, upon oath and under penalty of perjury, do depose and say as follows:

1. The decedent, ______, died Testate on______, a resident of

______County, in the State of ______.

2. On ______(date), the following person(s) was/were appointed as the of the Estate of ______by the ______(name of foreign court), of ______County, State of ______, being case number

______, if applicable.

a. Name: ______.

Address: ______.

b. Name: ______.

Address: ______.

3. An authenticated copy of the Last dated ______and the certificate of of such other state or jurisdiction is being furnished herewith for recording in this County.

4. The Decedent died owning and possessing the following real estate situated in West Virginia:

Assessed Fair Market Description: County Value Value

______

______

______

______

______

______

______

______

______

______

TOTAL:

5. Pursuant to the provisions of the Last Will and Testament of ______, the decedent devised

the aforesaid real estate to the following beneficiaries of the estate:

Recipient: Relationship: Share Percent:

TOTAL PERCENT:

6. The Estate of ______, the decedent, will be/has been fully administered by the domicillary

personal representative under the domicillary proceedings in the other state or jurisdiction. No appointment of an

ancillary personal representative to administer the decedent's real estate within the State of West Virginia is

necessary for any proper purpose.

7. I have personal knowledge of the above facts and am interested in the Estate of ______, the

decedent, as the ( ) acting domicillary personal representative, ( ) surviving spouse, ( ) beneficiary under the

decedent's will, ( ) heir at law, or ( ) other ______(describe relationship or

interest.) Please only check one.

______Date

The foregoing instrument was acknowledged before me this _____ day of ______, ______.

My Commission expires: ______. ______Notary Public NOTARY SEAL

Ancillary Affidavit