STATE OF [State]

COUNTY OF [County]

Introduction:

I, [Your Name], being duly sworn, do hereby declare and affirm as follows:

Statement of Facts:

1. My name is [Your Name], I am a resident of [Your Address], and I am the lawful surviving spouse of [Deceased Spouse’s Name], who passed away on [Date of Death].

2. I was legally married to [Deceased Spouse’s Name] on [Date of Marriage], in [Location of Marriage, City, State, Country]. Attached hereto as Exhibit A is a copy of our marriage certificate.

3. [Deceased Spouse’s Name] passed away on [Date of Death], as evidenced by the attached death certificate (Exhibit B).

4. To the best of my knowledge, [Deceased Spouse’s Name] held retirement accounts and life insurance policies listed as follows:

5. Retirement Account: [Account Details, Financial Institution] Life Insurance Policy: [Policy Number, Insurance Company]

6. I am the designated beneficiary of the above-mentioned accounts and policies.

Claim:

I hereby affirm my right and intent to claim the benefits due from the retirement accounts and life insurance policies mentioned herein, under the laws governing such accounts and policies.

Truthfulness and Legal Binding:

I affirm that the information provided in this affidavit is true and accurate to the best of my knowledge and belief. I understand that providing false information in this document can result in penalties under the law.

Signature:

[Your Name]

DATED this [Day] of [Month], [Year].

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