STATE OF ____________________)
COUNTY OF __________________)
|_____________________ ,||being duly sworn,|
|(Name of Affiant)|
deposes and says under the penalties of perjury that:
This Affidavit is submitted to
|(name of institution)|
(the "Institution"), for the purposes of accessing accounts or money market mutual fund shares held solely in the name of
|(Name of Presumed Deceased Depositor/Shareholder)|
(the "Deceased Depositor").
I am the (check appropriate box)
|q||spouse of the Deceased Depositor|
|q||guardian of the minor children of the Deceased Depositor
and the Deceased Depositor was not survived by a spouse
|q||person with whom the minor children of the Deceased Depositor reside
and the Deceased Depositor was not survived by a spouse.
The Deceased Depositor was either employed in the World Trade Center or the Pentagon, or was in such buildings, or in the immediate vicinity, when the events of September 11, 2001 occurred; or was a crew member or passenger on any of the airline flights involved in the disasters on that date; or was a police officer, fire fighter, emergency medical service provider, or rescue volunteer at one of those building sites on that date.
I have not seen or heard from the Deceased Depositor since September 11, 2001, and that barring his or her death, he or she would have been in contact with me or someone else.
I request that the Institution release to the undersigned the amount of $_________ from the Deceased Depositor's accounts or money market mutual funds.
I hereby release the Institution from all claims arising out of any release of any funds from such accounts or money market mutual funds, as a result of the filing of this Affidavit with the Institution.
I submit herewith a copy of my personal identification (preferably photo identification) .
I represent that the total of my withdrawals from all of the accounts and money market mutual funds held solely in the name of the Deceased Depositor do not exceed $15,000.
If I am acting on behalf of the Deceased Depositor's minor children I agree to use the funds I obtain solely for the benefit of such children.
In the event that it is determined that any amounts provided to me hereunder do not properly belong to me or to the minor children of the Deceased Depositor, I agree to return the same to the person who shall be determined to be entitled thereto.
(Signature of Affiant)
Sworn to before me this
day of ,