53 111 a Rev 9 215 AFFIDAVIT of HEIRSHIP THIS 2022-2026

53-111-A (Rev.9-21/5) AFFIDAVIT OF HEIRSHIP THIS AFFIDAVIT MUST BE FILED WITH THE COUNTY CLERK Link to 53-111-B The claimant must file this completed affidavit in the County Clerk’s record in the county of the decedent’s residence. The claimant must then upload a file stamped copy of the completed affidavit to ClaimItTexas.org. Name of reported owner: Claim number: Affidavit of facts concerning the identity of heirs for the estate of ________________________________________________________ NAME OF DECEASED PERSON (DECEDENT) Before me, the undersigned authority, on this day personally appeared: ___________________________________________________ PERSON COMPLETING THIS FORM (WITNESS) who, being first duly sworn, upon his/her oath states: SECTION A. WITNESS INFORMATION If additional space is needed for any of the fields below, please provide an attachment with the additional information. 1. My name is: _____________________________________________________________________________________________ My current address is I have personal knowledge of the family history and facts of heirship of: _ True I am not the claimant, and I will not benefit from the decedent’s estate. The decedent was my _______________. I knew the decedent for ______ years. RELATIONSHIP SECTION B. DECEDENT INFORMATION 2. Decedent died on DATE OF DEATH Decedent's residence at the time of decedent's death: ______________________________________________________________ CITY STATE COUNTY If no, continue completing this form. If yes, this form is not required and the claimant should submit the probated will. If no, continue completing this form. The claimant must provide a complete copy of the will along with this form. SECTION C. MARITAL AND FAMILY HISTORY List all marriages, including those that ended in divorce or death. Mark N/A if not applicable NAME OF SPOUSE DATE OF MARRIAGE DATE OF DIVORCE DATE OF SPOUSE'S DEATH CURRENT ADDRESS If yes, complete information below. If no, proceed to #6 NAME OF CHILD DATE OF BIRTH 5. Are any of the children listed in #4 deceased? NAME OF CHILD'S OTHER PARENT Yes No If yes, complete information below. If no, proceed to Section D – Attestation DECEASED CHILD INFORMATION NAME OF DECEASED CHILD DATE OF DEATH SURVIVING SPOUSE NAME (IF APPLICABLE) CURRENT ADDRESS CHILDREN OF DECEASED CHILD IS SPOUSE ALIVE? Y/N CHILD'S NAME DOB AND CURRENT ADDRESS IS CHILD ALIVE?Y/N CHILD'S OTHER PARENT (IF KNOWN) Form 53-111-A(Back)(Rev.1-21/6) Name of reported owner: Claim number: If yes to at least one of the above, proceed to Section D - Attestation 7. Provide the following information on the decedent's parents: IS THIS PARENT DECEASED? NAME OF PARENT IF YES, PROVIDE DATE OF DEATH CURRENT ADDRESS If yes, complete information below. If no, proceed to Section D – Attestation If yes, complete information below. If no, proceed to Section D – Attestation List all siblings, including half or adopted. Do not include stepsiblings unless adopted. NAME OF SIBLING AND CURRENT ADDRESS DATE OF BIRTH SIBLING MOTHER NAME SIBLING FATHER NAME If yes, complete information below. If no, proceed to Section D – Attestation DECEASED SIBLING INFORMATION NAME OF DECEASED SIBLING DATE OF DEATH SURVIVING SPOUSE NAME (IF APPLICABLE) CHILDREN OF DECEASED SIBLING IS SPOUSE ALIVE? Y/N CHILD'S NAME DOB AND CURRENT ADDRESS IS CHILD ALIVE?Y/N CHILD'S OTHER PARENT (IF KNOWN) **Section D must be completed in front of a notary public** SECTION D. ATTESTATION I swear under penalty of perjury that the foregoing is true, accurate, and complete to the best of my knowledge. Signed this __________day of ___________ , ______________________________ . _____________________________________________________________________ SIGNATURE OF WITNESS BEFORE NOTARY State of __________________________ County of _____________________________________________ Sworn to and subscribed to before me on __________________________________ DATE by ____________________________________________________________________________________ PRINTED WITNESS NAME ____________________________________________________________________________ NOTARY SIGNATURE (Notary Seal) My commission expires: __________ day of __________ , ____ . The claimant must file this completed affidavit in the County Clerk's record in the county of the decedent's residence. The claimant must then upload a file stamped copy of the completed affidavit to ClaimItTexas.org.