AFFIANT’S SIGNATURE SUBSCRIBED AND SWORN TO BEFORE ME THIS DATE: NOTARY PUBLIC MY COMMISSION EXPIRES: STATE OF HAWAII SEE FOLLOWING PAGE DECEASED STATE OF HAWAII ) ) SS: ) I, the undersigned affiant, being first duly sworn on oath, deposes and says: 1. I am the successor of the above named decedent. A certified copy of the death certificate is submitted with this affidavit. 2. The gross value of the decedent’s estate in this State (excluding the value of motor vehicles) does not exceed $100,000.00. 3. No application or petition for the appointment of a personal representative is pending or has been granted in this State. 4. I am entitled to payment or delivery of the property referred to above and itemized below by virtue of HRS Section 560:3-1201, as amended, and by virtue of my relationship to the decedent indicated above. 5. I have read and understand HRS Section 560:3-1202 which is printed on the reverse side of this affidavit. 6. I make this affidavit for the purpose of collecting the following personal property: AFFIDAVIT FOR COLLECTION OF PERSONAL PROPERTY OF THE DECEDENT AFFIDAVIT FOR COLLECTION OF PERSONAL PROPERTY OF THE DECEDENT 3C-E-210 In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if you require a reasonable accommodation for a disability when working with a court program, service or activity, please contact the ADA Coordinator at (808) 961-7424, FAX (808) 961-7411, or email [email protected] at least ten (10) working days before your proceeding, hearing or appointment date. RG-LC-508 (8/2014) THE ESTATE OF DATE OF DEATH RELATIONSHIP OF AFFIANT TO DECEDENT Continuation page attached. TYPE OR PRINT NAME AND RESIDENCE OF AFFIANT