Such affidavit shall state that such individuals qualify as the proper relation to the decedent as specified in this subsection, there is no known will of the decedent, and that there are no other known corresponding claimants to such deposit.
provided, however, that, if any payment is made pursuant to subsection (c) of this Code section by an employee of the financial institution who is without actual knowledge of such written notification or service of notice within three business days following the receipt of such written notification or service of notice by the registered agent of the financial institution, the protection provided by paragraph (1) of this subsection shall extend to any such payment.
"State of Georgia County of __________________
STATUTORY AFFIDAVIT FORM
__________________ from | __________________ attests that |
(Claimant) | (Facility) |
__________________ died on the __________________ day of __________________, 20__________________. | |
(Deceased) | |
On information and belief, the Deceased has funds on deposit with | |
__________________. | |
(Financial Institution) |
Under O.C.G.A. § 7-1-239, such Financial Institution is authorized to pay the proceeds of the Deceased's deposits, but in no event more than $15,000.00, directly to the following persons identified, collectively, as potential recipient(s):
Except as provided for by Article 8 in Title 7 of the O.C.G.A., if no request for the Deceased's deposit is made by a potential recipient(s) within 45 days from the Deceased's death, the Financial Institution is authorized to release up to $15,000.00 for funeral expenses and expenses of the last illness of the Deceased upon the receipt of itemized statements of such expenses and this executed attestation.
The Claimant attests that there is no known will of the Deceased and there is no known potential recipient of the Deceased's deposits. The Claimant also attests that funeral expenses or expenses of the last illness in the amount of $__________________ were incurred related to the Deceased and that true and correct copies of the itemized receipts fully supporting such amount are attached to this affidavit. Finally, the Claimant further attests that such expenses have not been paid as of the date of execution of this affidavit.
Pursuant to O.C.G.A. § 7-1-239, the Claimant submits this form in order to receive payment in the amount of $__________________ (shall not exceed $15,000.00) for outstanding funeral expenses or expenses of the last illness of the Deceased.
__________________
Signature of Claimant
Sworn and subscribed
before me this __________________ day
of __________________, 20__________________.
__________________
Notary public (SEAL)
My commission expires: __________________."
OCGA § 7-1-239