Affidavit of No Estate

I, __________________________, do state that, __________________________,

died on ____________________________, leaving no will and no executor or

administrator has been or will be appointed to the estate. Funeral expenses total

$___________________ and I am responsible for these expenses.

Beneficiary: _______________________________ Date: _______________

Witness: _______________________________ Date: _______________

Revision: 03/31/2017

Serviced By Brandon Martin

P.O. Box 1666 ♦ Gadsden, Alabama 35902 ♦ Phone: (256) 547-6998 ♦ Fax: (256) 547-0623 Email: info@ncmutualfinancial.com ♦ Website: www.ncmutualfinancial.com