STATE OF MISSOURI
COUNTY OF [County]

Introduction:

I, [YOUR NAME], of [YOUR ADDRESS], being duly sworn, declare under penalty of perjury that:

Statement of Facts:

1. The decedent, [Decedent's Name], passed away on [Date of Death] in [Decedent's Address]. At the time of their passing, they were residing at [Decedent's Address], which was their legal residence.

2. I, the undersigned, hold the relationship of [Your Relationship to the Decedent] to the decedent and am providing this information in my capacity as such.

3. My current mailing address, where all correspondences regarding this matter can be sent, is [YOUR ADDRESS]. This statement is furnished to outline my connection to the decedent and to provide essential details about their death and residency for the purposes associated with settling their estate.

4. The value of the entire personal property of the decedent's estate, wherever situated, does not exceed $40,000, the statutory limit for small estates in Missouri. No application or petition for the appointment of a personal representative is pending or has been granted in any jurisdiction.

5. The undersigned agrees to use the assets collected from the decedent's estate to pay debts and expenses of the decedent’s estate in the order prescribed by law.

Purpose of Affidavit:

The affidavit is executed to collect the funds from the decedent’s bank account at [Bank Name, Account Number(s)], to be used specifically for the payment of final expenses and distribution according to the laws of intestate succession of the State of Missouri.

Legal Declarations:

I declare that all statements in this affidavit are true and correct to the best of my knowledge and belief and that this affidavit is being made for the purposes of collecting the personal property of the decedent as entitled by Missouri law.

DATED this [DAY] of [MONTH], [YEAR].

Signature:

[YOUR NAME]

[Notary's Name]

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