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 competent to make this affidavit.

2. I am a resident of [CITY NAME], Wyoming.

3. I am the [RELATIONSHIP TO DECEASED] of the deceased, [DECEASED'S NAME], who passed away on [DATE OF DEATH] in [CITY NAME], Wyoming.

4. The deceased was a resident of [CITY NAME], Wyoming at the time of his/her death.

5. The deceased was the holder of an insurance policy with [INSURANCE COMPANY NAME], policy number: [POLICY NUMBER], with coverage for [TYPE OF COVERAGE].

Sworn Oath

I solemnly swear that the foregoing statements are true and correct to the best of my knowledge and belief. I understand that making false statements in this affidavit is a criminal offense punishable by law.

Executed this [DATE OF EXECUTION] in [CITY NAME], Wyoming.

[YOUR NAME]

Affiant

Witness Statement

I hereby certify that on [DATE OF EXECUTION], [YOUR NAME] appeared before me and signed or acknowledged signing this affidavit. I further certify that I am not a party to this action and am not related by blood or marriage to any party to this action.

[WITNESS NAME]

Witness

Notary Acknowledgment

State of Wyoming

County of [COUNTY NAME]

On this [DATE OF NOTARIZATION], before me, a Notary Public in and for said County and State, personally appeared [YOUR NAME], known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he/she executed the same for the purposes therein contained.

Notary Public

My Commission Expires: [NOTARY EXPIRY DATE]

[NOTARY SEAL]

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