Free Connie-B.wpt - North Dakota

ND PROBATE CODE FORM 7 -- AFFIDAVIT FORWARDING COPY OF APPLICATION TO DEPARTMENT OF HUMAN SERVICES.

10/01/03

IN DISTRICT COURT

IN THE MATTER OF THE ESTATE OF ______________________________________________________, DECEASED.

AFFIDAVIT FORWARDING COPY OF APPLICATION TO DEPARTMENT OF HUMAN SERVICES

STATE OF NORTH DAKOTA

} } County of ____________________ }

ss.

___________________________________________________________________________, being first duly sworn on oath, deposes and says that I am the ____________________________ of the Estate of ______________________________, Deceased; and That I did forward copies of the application commencing probate proceedings, together with a list of the names of the legatees, devisees, surviving joint tenants, and heirs at law to the estate to the North Dakota Department of Human Services, State Capitol, Bismarck, North Dakota 58505, pursuant to Sections 50-06.3-07 and 50-24.1-07, N.D.C.C.. Dated __________________________________________, __________. ____________________________________________

Subscribed and sworn to before me this ____________________ day of ____________________________, __________.

____________________________________________ Notary Public _________________________, County, North Dakota (Seal) My commission expires:_________________________