(4) The family member may use an affidavit in substantially the following form to fulfill the requirements of subsection (3): AFFIDAVIT UNDER SECTION 735.303, FLORIDA STATUTES, TO OBTAIN BANK PROPERTY OF DECEASED ACCOUNT HOLDER: (Name of decedent)
State of
County of
Before the undersigned authority personally appeared (name of affiant), of (residential address of affiant), who has been sworn and says the following statements are true:
(a) The affiant is (initial one of the following responses): The surviving spouse of the decedent.
A surviving adult child of the decedent, and the decedent left no surviving spouse.
A surviving adult descendant of the decedent, and the decedent left no surviving spouse and no surviving adult child.
A surviving parent of the decedent, and the decedent left no surviving spouse, no surviving adult child, and no surviving adult descendant.
(b) As shown in the certified death certificate, the date of death of the decedent was (date of death), and the address of the decedent's last residence was (address of last residence) .(c) The affiant is entitled to payment of the funds in the decedent's depository accounts and certificates of deposit held by the financial institution (name of financial institution). The total amount in all qualified accounts held by the decedent in all financial institutions known to the affiant does not exceed an aggregate total of $1,000. The affiant requests full payment from the financial institution.(d) A personal representative has not been appointed to administer the decedent's estate, and no probate proceeding or summary administration procedure has been commenced with respect to the estate.(e) The affiant has no knowledge of any last will and testament or other document or agreement relating to the distribution of the decedent's estate.(f) The payment of the funds constitutes a full release and discharge of the financial institution regarding the amount paid.(g) The affiant understands that he or she is personally liable to the creditors of the decedent and other persons rightfully entitled to the funds under the Florida Probate Code, to the extent the amount paid exceeds the amount properly attributable to the affiant's share.(h) The affiant understands that making a false statement in this affidavit may be punishable as a criminal offense. By (signature of affiant)
Sworn to and subscribed before me this day of by (name of affiant), who is personally known to me or produced as identification, and did take an oath.
(Signature of Notary Public - State of Florida)
(Print, Type, or Stamp Commissioned Name of Notary Public)
My commission expires: (date of expiration of commission)