Washington County

Washington County Clerk of Circuit Court Probate Division

Transfer by Affidavit ($50,000 and Under) Revised State Form No. PR- 1831 September 8, 2014 GUIDELINE: 3032 Sec. 867.03, Wis. Stats Page 1 of 1

PLEASE NOTE: This Guideline is provided as a public service and is not intended to be legal advice. If you have any questions, about the form or the procedure, please contact an attorney as Probate staff members cannot give legal advice. ABOUT THE FORM: This form was developed by the State as the simplest procedure for probate in the State of Wisconsin. An heir, guardian or trustee completes and processes the form on their own. It is not filed with the Courts. However, if the deceased had a Will and this form is used, the original Will is still required to be filed with the Register in Probate. If you do not understand the form or the procedure, please contact an attorney for legal assistance. WHEN TO USE THE FORM: when a decedent leaves property subject to administration in the State of Wisconsin which does not exceed $50,000 in value. This amount does not include assets that are:  Held jointly with someone else  “Payable on death” (POD) to someone else  “Transferrable on death” (TOD) to someone else  Have a specific beneficiary, such as a life insurance policy WHERE IS THE FORM? This State form is available on the internet as a fillable Word document PR-1831.DOC and as a PDF document PR-1831.PDF which may be printed and filled in by hand. Additionally, please review brochure at: http://www.dhs.wisconsin.gov/publications/p1/p13009.pdf and the Fact Sheet at: http://www.dhs.wisconsin.gov/publications/P0/P00694.pdf HOW TO USE THE FORM:  An heir, guardian or trustee completes all sections of the form, inserting the name of the County where the deceased resided at the very top of the form.  Answer all questions, #1 through #6.  Read #7 and on page 2 of the form list all the assets/property of the deceased subject to administration including the name, address, account number or any other pertinent information and where the asset is held, or enter a legal description if appropriate. Enter the amount of each asset in the “Gross Value” column.  Read #8 and #9 on page 2 to understand your obligation if the asset(s) transfer to you.  Do Not sign this form until you swear to it in front of a Notary Public.  When the form is complete, including your notarized signature, make at least 2 copies of the form.  If the deceased was not on Medicaid (Title XIX, Title 19), take the original form and the death certificate to the financial institution(s). If the deceased received Medicaid (Title XIX, Title 19) or any other program:  Send a COPY of the completed form via certified mail, return receipt requested, to the Department of Health Services at the address noted on last page of the form.  Wait until the green certified mail card indicating the date on which the Department of Health Services received your notification is returned to you.  10 days after that date, take the original Affidavit and the death certificate to the financial institution(s) to transfer the asset(s). PLEASE NOTE:  Some financial institutions may require notification of the Department of Health Services even if the deceased did not receive Medicaid (Title XIX, Title 19).  Please read all the information and other instructions on the last page of the form.  The forms are not filed with the Register in Probate. If you are transferring real estate, you may need to “record” this document with the Register of Deeds.

Clerk of Circuit Court Phone: (262) 335-4334 Washington County Courthouse Justice Center, Room 3135 Fax: (262) 306-2224 432 East Washington Street Office Hours: Office Website: P.O. Box 1986 Monday – Friday www.co.washington.wi.us West Bend, WI 53095-7986 8:00 a.m. – 4:30 p.m. Sec. 867.03, Wis. Stats.

Clerk of Circuit Court Phone: (262) 335-4334 Washington County Courthouse Justice Center, Room 3135 Fax: (262) 306-2224 432 East Washington Street Office Hours: Office Website: P.O. Box 1986 Monday – Friday www.co.washington.wi.us West Bend, WI 53095-7986 8:00 a.m. – 4:30 p.m.