Opinion
3:13-md-02452-AJB-MDD
03-30-2022
In Re: Incretin Mimetics Products Liability Litigation
DECLARATION OF PROPOSED INTERIM ESTATE REPRESENTATIVE (INTESTATE DECEDENT)
I, [NAME OF DECLARANT (“declarant”), declare as follows:
1. I am over the age of 18 years. I have personal knowledge of the facts contained in this declaration, and if called as a witness I could and would testify competently to the truth of the facts stated herein.
2. I am the [RELATIONSHIP] of [NAME OF DECEDENT] (“decedent”) who died on [INSERT DATE OF DEATH], in [CITY], [STATE]. The decedent died intestate and I am a beneficiary of the estate who succeeds to a cause of action. The other beneficiaries are [NAMES OF HEIRS].
3. With respect to any surviving spouse and/or surviving children of the decedent who succeeds to a cause of action [Must select one of the three below]:
[ ] Any surviving spouse and all surviving children are among those identified in paragraph 2, above;
OR
[ ] To the extent not among those identified in paragraph 2, the surviving spouse and/or surviving children are [NAMES OF SURVIVING SPOUSE AND/OR SURVIVING CHILDREN]
OR
[ ] The decedent had no surviving spouse and no surviving children.
4. With respect to minor children:
[ ] None of the surviving children or beneficiaries identified in paragraphs 2 and/or 3, above, are minor children;
OR
[ ] The following surviving children or beneficiaries are minor children, and their age and relationship to the decedent are as noted.
Name: __________
Age: __________
Relationship: __________
5. No proceeding is now pending or has been filed at any time in the past in any state or federal court for administration of the decedent's estate.
6. All persons identified in paragraphs 2 and 3 above consent to my appointment as the Interim Estate Representative for the decedent's estate in accordance with the Order of this Court dated ______, 2014.
7. No other person has a superior right to commence the action or proceeding or to be substituted for the decedent in the pending action or proceeding.
8. A certified copy of the decedent's death certificate is attached hereto. Executed on the [DAY] of [MONTH], 20 __.
9. I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct.
[NAME OF DECLARANT]
EXHIBIT B
DECLARATION OF PROPOSED INTERIM ESTATE REPRESENTATIVE (INTESTATE DECEDENT)
I, [NAME OF AFFIANT] (“affiant” or “declarant”), declare as follows:
1. I am over the age of 18 years. I have personal knowledge of the facts contained in this declaration, and if called as a witness I could and would testify competently to the truth of the facts stated herein.
2. I am the [RELATIONSHIP] of [NAME OF DECEDENT] (“decedent”) who died on [INSERT DATE OF DEATH], in [CITY], [STATE], and [Must select one of the two boxes below]:
I am a named beneficiary of the will of the decedent. The other named beneficiaries who succeed to a cause of action under the Will are [NAMES OF HEIRS].
OR
I am the sole beneficiary named in decedent's will.
OR
I am authorized by the decedent's will to act on behalf of the decedent's beneficiary or beneficiaries with respect to the decedent's interest in this action or proceeding. The named beneficiary or beneficiaries who succeed to a cause of action under the Will are [NAMES OF HEIRS].
3. With respect to any surviving spouse and/or surviving children of the decedent [Must select one of the three boxes below]:
[ ] Any surviving spouse and all surviving children are among those identified in paragraph 2, above;
OR
[ ] To the extent not among those identified in paragraph 2, are as follows [NAMES OF SURVIVING SPOUSE AND/OR SURVIVING CHILDREN]
OR
[ ] The decedent had no surviving spouse and no surviving children.
4. The decedent's Personal Representative as identified in the Will is .
5. With respect to minor children:
[ ] None of the surviving children or beneficiaries identified in paragraphs 2 and/or 3, above, are minor children;
OR
[ ] The following surviving children or beneficiaries are minor children, and their age and relationship to the decedent are as noted.
Name: _______
Age: _______
Relationship: _______
6. No proceeding is now pending or has been filed at any time in the past in any state or federal court for administration of the decedent's estate.
7. All persons identified in paragraphs 2 and 4 above consent to my appointment as the Interim Estate Representative for the decedent's estate in accordance with the Order of this Court dated, _______ 20__.
8. No other person has a superior right to commence the action or proceeding or to be substituted for the decedent in the pending action or proceeding.
9. A certified copy of the decedent's death certificate is attached hereto. Executed on the [DAY] of [MONTH], 20.
10. I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct.
Executed on the __ day of the __ Month, 20 __.
[NAME OF DECLARANT]