Introduction

I, [YOUR NAME], being duly sworn, depose and state as follows:

Statement of Facts

1. I am over the age of eighteen (18) years and am of sound mind and competent to make this affidavit.

2. I am a resident of [CITY NAME], State of Washington, and have personal knowledge of the facts stated herein.

3. [DECEASED'S NAME], hereinafter referred to as the "Decedent," was a resident of [CITY NAME], State of Washington.

4. The Decedent passed away on [DATE OF DEATH] in [CITY NAME], State of Washington.

5. Attached hereto and incorporated herein as Exhibit A is a certified copy of the Decedent's death certificate issued by the Washington State Department of Health, which certifies the Decedent's death on the aforementioned date.

6. The Decedent was the insured under a life insurance policy issued by [INSURANCE COMPANY NAME], policy number [POLICY NUMBER].

7. The undersigned is a beneficiary under said life insurance policy and is entitled to claim the benefits thereunder.

Sworn Oath

I declare under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct.

Executed on [DATE OF EXECUTION] at [CITY NAME], State of Washington.

[YOUR NAME]

Affiant

Notary Acknowledgment

State of Washington

County of [COUNTY NAME]

Subscribed and sworn to before me on [DATE OF EXECUTION], by [YOUR NAME], proved to me based on satisfactory evidence to be the person(s) who appeared before me.

Notary Public in and for the State of Washington

My commission expires: [EXPIRATION DATE]

[NOTARY SEAL]

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