I, ______________________, residing at _______________________in __________________, being of full legal age, for the purpose of establishing the legal ownership of certain land in _______________County,_______________ , proposed to be purchased by the United States of America from all the lawful heirs of__________________late of ________________,
_____________County, State of __________________, who died on the ________day of ______________, 20__, at the age of ______years, a resident of _______County, State of ______________, on oath depose and say as follows:
(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 20__, 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:
_____________________________________________________________________
Full name, relationship to decedent, age, married to, 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.
__________________________
____________________ , 20___
____________________________
____________________________, ss:
Then personally appeared before me the above-named _________________________, who subscribed the foregoing affidavit and made oath that the statements contained therein are true.