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 personal representative 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 Will and Testament dated ______and the certificate of probate 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