Introduction

I, [YOUR NAME], being of sound mind and legal age, do hereby solemnly affirm and declare the following information regarding the heirs of [DECEDENT'S NAME], hereinafter referred to as the "Decedent," who passed away on [DECEDENT'S DEATH DATE]:

Statement of Facts

1. The Decedent, [DECEDENT'S NAME], was a resident of [COUNTY NAME], Nebraska, at the time of their death.

2. I am a [RELATIONSHIP TO DECEDENT] of the Decedent and have personal knowledge of the family history and heirs.

3. To the best of my knowledge, the Decedent did not leave a Last Will and Testament at the time of their death.

4. The heirs of the Decedent, along with their respective relationships to the Decedent, are as follows:

   • [HEIR'S NAME]: [RELATIONSHIP TO DECEDENT]

5. There are no known disputes or contests regarding the Decedent's estate or the distribution of assets among the heirs listed herein.

6. We, the undersigned heirs, hereby declare that we are entitled to any insurance benefits, proceeds, or claims payable to the estate of the Decedent under the policy(ies) issued by [INSURANCE COMPANY NAME], policy number [POLICY NUMBER].

7. We understand that the information provided in this Affidavit of Heirship is true and accurate to the best of our knowledge and belief. We acknowledge that providing false information may result in legal consequences.

We hereby request that [INSURANCE COMPANY NAME] process any insurance claims or benefits payable to the estate of the Decedent in accordance with the information provided herein.

Signature

Signed under penalty of perjury this [DATE].

[YOUR NAME]

[NOTARY PUBLIC NAME]

[NOTARY PUBLIC EXPIRY DATE]

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