North Dakota Affidavit of Death

Introduction

I, [YOUR NAME], being duly sworn, depose and state as follows:

• I am over the age of eighteen (18) years and am of sound mind and competent to make this Affidavit.

• I am the [RELATIONSHIP TO DECEASED], and I have personal knowledge of the facts stated herein.

Statement of Facts

1. [DECEASED'S NAME], the decedent, passed away on [DATE OF DEATH], in [COUNTY NAME], North Dakota.

2. The decedent was a resident of [COUNTY NAME], North Dakota at the time of death.

3. Attached hereto and incorporated herein as Exhibit A is a true and correct copy of the death certificate of the decedent issued by the relevant authority.

Sworn Oath

I hereby swear under penalty of perjury that the foregoing statements are true and correct to the best of my knowledge, information, and belief.

Signed this [DATE] day of [MONTH], [YEAR].

[YOUR NAME]

Affiant

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Notary Acknowledgment

State of North Dakota

County of [COUNTY NAME]

On this [DATE] day of [MONTH], [YEAR], before me, a Notary Public in and for said County and State, personally appeared [YOUR NAME], known to me to be the person whose name is subscribed to the foregoing instrument, and acknowledged that he/she executed the same for the purposes therein contained.

Notary Public

My Commission Expires: [COMMISSION EXPIRY DATE]

[NOTARY SEAL]

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