(1) That I was personally acquainted with the above-named decedent for the period of ________years from _____________until his death, and that my relationship to said decedent was ____________________________.
(2) That said decedent was married to _________________at __________________ in 19__, who (survived) (predeceased) said decedent.
(3) That the following is a list
of the full names, relationships to the decedent, ages, marital status,
and addresses of all surviving issue or other heirs of said decedent:
Relationship Age Married
Full name Decedent Address
(4) (That said decedent left no will, no issue, or no collateral heirs other than those named above and no unpaid debts or claims except as stated below.)
(That I have made careful inquiry and that to the best of my information and belief said decedent left no will, no issue, or no collateral heirs other than those named above, and no unpaid debts or claims except as stated below.)
(5) That the value of the decedent's entire estate at death, including all property, real and personal, then owned by the decedent, did not exceed $____________.
(6) That I am (not) interested
financially or by reason of relationship to said decedent in the proposed
conveyance to the United States of America in connection with which this
affidavit is furnished, and understand that it is secured for the purpose
of inducing the United States to purchase land owned by said decedent.
____________________ , 19___
Then personally appeared
before me the above-named _________________________, who subscribed the
foregoing affidavit and made oath that the statements contained therein