OFFICE OF THE SECRETARY OF STATE
REGISTRATION OF CLAIM FOR THE USE OF A DECEASED INDIVIDUAL'S NAME, VOICE,
SIGNATURE, PHOTOGRAPH, OR LIKENESS (Texas Property Code, Section 26.006) 1. The legal name of deceased individual: ___________________________________________________________________________________ 2. Other names by which deceased individual was known: ___________________________________________________________________________________ ___________________________________________________________________________________ 3. Date of death of deceased individual: _______/________/_________ 4. Name of claimant: ________________________________________________________________________ 5. Address of claimant: ________________________________________________________________________ _________________________________________________________________________ 6. Basis of claim [Check appropriate statement] I make this claim as successor-in-interest on the basis that: _________ (1.) I am the Independent Executor or __________________________________________ of the Estate of ___________________________________________, OR _________ (2.) I am the surviving OR _________ (3.) The property rights of said deceased individual have been transferred to me by ( ) contract 7. Statement of the right claimed: A. Percentage of interest claimed:
) 100% ( ) 50% ( ) 25% ( ) _______% ( ) trust ( ) will.
( ) spouse
( ) child
( ) grandchild
( ) parent,
B. The above percentage is claimed in 1
) All types of rights OR
( ) Limited rights described as follows: __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________ Signature of Claimant STATE OF ___________________________
COUNTY OF _________________________
Before me, a notary public, on this day personally appeared ______________________________, known to me to be the person whose name is subscribed to the foregoing document and, being by me first duly sworn, declared that the statements therein contained are true and correct. Given under my hand and seal of office this ______ day of ______________________, _________
_____________________________________ Notary Public Signature _____________________________________ Notary Public Printed or Typed Name My commission expires:_______________ *************************************************************
INSTRUCTIONS 1. 2. The filing fee is $25.00. The check should be made payable to the Secretary of State. The completed form and filing fee should be sent to the Office of the Secretary of State, Statutory Documents Section, P.O. Box 13550, Austin, TX 78711-3550. The claim is filed pursuant to Section 26.006 of the Texas Property Code. The date of filing is the date of receipt by the Secretary of State of a properly executed form and the required $25.00 filing fee. The claim will not be filed if any of the statements on the claim are not completed, the statement is not properly signed and verified or the filing fee has not been submitted. A rejection letter will be sent stating the reason or reasons the claim was not filed. Any questions should be directed to (512) 475-1769.