W. Va. Code § 44-1A-2
(b) Any successor of a decedent who dies domiciled in this state, without owning any probate real property or without owning any interest in probate real property, may execute and tender for recording to the clerk of the county commission, or the fiduciary supervisor of the clerk of the county commission, of the county in this state which would have jurisdiction over the probate concerning the estate and assets of the decedent an affidavit made upon oath and under penalty of perjury concerning the small estate setting forth in substance:
(e) A document substantially in the following form may be used as the affidavit provided in subsection (b) of this section with the effect as prescribed in this article:
IN THE COUNTY COMMISSION OF __________ COUNTY, WEST VIRGINIA
RE: THE ESTATE OF ______________________
DOD: _____________________
AFFIDAVIT FOR SMALL ESTATE
STATE OF ________________,
COUNTY OF ______________, to-wit:
I, ______________________________, being a Successor of the Decedent identified below, being first duly sworn, upon oath and under penalty of perjury, do depose and say to the best of my knowledge and belief as follows:
1. My name is ______________________________, and my current address is ________________________________________________________________________________________________________________________________________________________.
2. The Decedent, ______________________________________________, died on _____________________ (date of death), a resident of ___________________ County, State of West Virginia, with his/her usual residence being ________________________________________________________________________________________________________________________________________________________. A certified death certificate has been furnished herewith for filing in this County. I am a Successor of the decedent as ______________________________ (state relationship).
3. TESTACY ( ) [Check if applies] or ( ) [Check if Not Applicable]
At the date of death, the Decedent died with an original Last Will and Testament of the Decedent dated _____________________, without any codicil thereto ( ) or with codicil(s) thereto dated ____________________ ( ) [Check if applies]. The aforesaid original Last Will and Testament of the decedent, together with any codicil(s), is furnished herewith for recording in this County as permitted by West Virginia Code § 44-1A-2(b).
Under the Last Will and Testament of the Decedent, the following person(s) is/are nominated to be the personal representative(s) of the Estate:
a. Name:________________________________________________
Address: ________________________________________________
_______________________________________________________
b. Name:________________________________________________
Address: ________________________________________________
_______________________________________________________
Pursuant to the provisions of the above referenced Will of the Decedent, the following persons are the named beneficiaries of the estate of the Decedent:
a. Name: _______________________________________________
Address: _______________________________________________
_______________________________________________________
Relationship to Decedent: __________________________________
Share or percentage or particular item: ________________________
b. Name: _______________________________________________
Address: ________________________________________________
_______________________________________________________
Relationship to Decedent: __________________________________
Share or percentage or particular item: ________________________
c. Name: ________________________________________________
Address: _______________________________________________
_______________________________________________________
Relationship to Decedent: __________________________________
Share or percentage or particular item: ________________________
d. Name: _______________________________________________
Address: ________________________________________________
_______________________________________________________
Relationship to Decedent: __________________________________
Share or percentage or particular item: ________________________
e. Name: ________________________________________________
Address: ________________________________________________
________________________________________________________
Relationship to Decedent: ___________________________________
Share or percentage or particular item: _________________________
(If more space is needed, attach additional page(s) to affidavit)
4. INTESTACY ( ) [Check if applies] or ( ) [Check if Not Applicable]
At the date of death, the Decedent died intestate with no known will. The Decedent left as his/her heirs-at-law and distributees in accordance with the laws of intestate descent and distribution of the State of West Virginia the following persons:
a. Name: ________________________________________________
Address: ________________________________________________
Relationship to Decedent: ___________________________________
Share or percentage: ______________________________________
b. Name: ________________________________________________
Address: _________________________________________________
Relationship to Decedent: ____________________________________
Share or percentage: ______________________________________
c. Name: ________________________________________________
Address: ________________________________________________
Relationship to Decedent: ___________________________________
Share or percentage: ______________________________________
d. Name: ________________________________________________
Address: ________________________________________________
Relationship to Decedent: ___________________________________
Share or percentage: _______________________________________
e. Name: ________________________________________________
Address: _________________________________________________
Relationship to Decedent: ____________________________________
Share or percentage: _______________________________________
(If more space is needed, attach additional page(s) to affidavit)
5. The Decedent's entire personal probate estate, as of the date of the Decedent's death, wherever located, consists only of small assets and the aggregate fair market value of the small assets does not exceed $50,000. The small assets of the Decedent are described and itemized as follows:
| Description | Fair Market value | |
| a. | ||
| b. | ||
| c. | ||
| d. | ||
| e. | ||
| f. | ||
| Total |
(If more space is needed, attach additional page(s) to affidavit)
| 6. The Decedent did not ( ) die seized and possessed of any probate real estate or interests in probate real estate in the state of West Virginia. | ||||
7. ( ) [Check if applies] or ( ) [Check if Not Applicable] If the affiant is a Successor who was nominated as a personal representative or executor under the provisions of the above Will of the Decedent, at least 30 days have elapsed since the Decedent's date of death and no application for the appointment of a personal representative for the Decedent is pending or has been granted in any jurisdiction;
or
( ) [Check if applies] or ( ) [Check if Not Applicable] If the affiant is a Successor who was NOT nominated as a personal representative or executor under the provisions of the above Will of the Decedent or if the Decedent died intestate without a will, at least 60 days have elapsed since the Decedent’s date of death and no application for the appointment of a personal representative for the Decedent is pending or has been granted in any jurisdiction, and no affidavit of Small Estate has been filed by a Successor nominated as a personal representative or executor under the provisions of the Will of the Decedent.
8. The undersigned Affiant will faithfully administer the small assets of the Decedent in accordance with the law and pay or deliver the same to the Successor or Successors so entitled.
Witness my hand and seal this ____ day of __________, 20___.
______________________________
Signature of Affiant/Successor
Taken, subscribed, and sworn to before me the undersigned authority by _________________________________, this ____ day of __________, 20___.
{seal}
My Commission expires: ______________________________
__________________________________________________
Notary Public