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Wisconsin Affidavit of Transfer

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Wisconsin Affidavit of Transfer
Wisconsin Affidavit of Transfer
PR-1831, 10/10 Transfer by Affidavit ($50,000 and under) §867.03, Wisconsin Statutes
This form shall not be modified. It may be supplemented with additional material.
STATE OF WISCONSIN, COUNTY
IN THE MATTER OF
Decedent
Register of deeds recording area
Name and return address
Note: Use black ink only.
Transfer by Affidavit
($50,000 and under)
parcel identification number
UNDER OATH, I STATE THAT:
1. The decedent, with date of birth and date of death ,
was domiciled in County, State of , with a mailing
address of .
2. I am: an heir, having the following relationship to the decedent: .
the person who was guardian of the decedent at the time of the decedent’s death.
trustee of a revocable trust created by the decedent.
3. The total gross value of the decedent’s property subject to administration in Wisconsin on the date of death did not
exceed $50,000.
4. The total gross value of the decedent’s property subject to administration in Wisconsin at the date of decedent’s
death was $ .
5. The decedent:
did did not receive Medical Assistance/Medicaid.
did did not receive Family Care and/or Partnership benefits (through a Managed Care
Organization – MCO/CMO).
did did not receive benefits from the Community Options Program (COP).
did did not receive benefits from the Wisconsin Chronic Disease Program.
was was not patient or inmate of a state or county hospital or institution, or responsible for any
person owing an obligation to the state or county. If so, explain:
The affiant lacks information to complete this section.
6. If the decedent was ever married, complete the following: (If more than one spouse, see attached.)
Name of spouse ( living or deceased): .
Married to decedent Divorced from decedent at time of decedent’s death.
The spouse did did not receive benefits from the Community Options Program (COP).
The spouse did did not receive benefits from the Wisconsin Chronic Disease Program.
The affiant lacks information to complete this section.
7. I ask that the following property be transferred to me under §867.03(1g), Wisconsin Statutes:
Wisconsin Affidavit of Transfer
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