DS-5511 Affidavit for the Surviving Spouse or Next of Kin

I, being duly sworn according to law, declare that I reside atStreet Address and that on Date of Death Name of Deceased had permanent legal residence atComplete Address of the Deceased. I am the Specify: widow, widower, child, father, mother, sibling, otherYour Nameand as such am entitled to receive the decedent's estate under the laws of Name of state/foreign state in the United States or foreign country where the deceased last had a permanent legal residence. To the best of my knowledge,U. S. Department of StateAFFIDAVIT FOR THE Surviving Spouse OR next OF KIN *Provide information below to the extent that it is of Deceased did/did not have a will or trust specifying the disposition of his or her (S) OF SURVIVORS, IN ORDER OF KINSHIP Please insert the name of living relatives in the following order of relationship: Surviving Spouse , children , father and/or mother, brothers and/or sisters, other:Date of Birth Telephone NumberRelationshipAddressName DS-551110-2008 Page 1 of 3(Including City, State/or Country)(mm-dd-yyyy)CONSULAR OFFICES OF THE UNITED STATES OF AMERICA(mm-dd-yyyy)Date of Birth Telephone NumberRelationshipAddressSignature of AffiantSubscribed and sworn to before me by Type Name of AffiantDateAddress of Notary PublicSignature of Notary PublicType Name of Notary PublicNamePage 2 of 3DS-5511(mm-dd-yyy)

Please insert the name of living relatives in the following order of relationship: surviving spouse, children, father and/or mother, brothers and/or sisters, other: Date of Birth Name Address Telephone Number Relationship DS-5511 10-2008 Page 1 of 3 (Including City, State/or Country) (mm-dd-yyyy) CONSULAR OFFICES OF THE UNITED STATES OF AMERICA

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