Missouri Beneficiary Deed

 Affidavit As To Death of Owner

 Request Form

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Deceased Owner's Name as set forth in original deed (send copy of such deed):

__________________________________________________________________________

Date of Death of Owner (send copy of Death Certificate):

__________________________________________________________________________

Relationship of Deceased Owner to Surviving Owner:

__________________________________________________________________________

Missouri County Where Real Property is Located:

__________________________________________________________________________

Missouri City Where Real Property is Located:

__________________________________________________________________________

Address of Real Property:

__________________________________________________________________________

__________________________________________________________________________

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Your Full Name:

_________________________________________________________________________

Your Relationship to Surviving Owner:_____________________

Your Mailing Address:

________________________________________________________________________

________________________________________________________________________

Your Telephone Number:

_______________________________________________________

Your Signature:

_______________________________________________________

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Surviving Owner's Mailing Address:

_______________________________________________________________________

_______________________________________________________________________

Surviving Owner's Telephone Number:

_______________________________________________________

Signature of Owner:

_______________________________________________________

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By signing above you agree this form will serve as the written agreement between yourself and Michael J. Denk, Attorney at Law, to draft and provide you with one (1) Affidavit per your request and information as set forth on this form. The cost is $100.00 per affidavit. The filing/recording of your Affidavit and the filing fee as charged by the appropriate Recorder of Deeds office will be your responsibility. You understand and agree no legal advice is being provided to you and you should consult with an Attorney of your choice for such advice. You hereby release Michael J. Denk and Missouri Beneficiary Deed, LLC from any and all claims relating to your use of such Affidavit. If you have any questions or concerns please contact us prior to signing and returning this form. Thank you.

Fill in all information on this form and then mail such form with (i) payment, (ii) a copy of the original deed, and (iii) a copy of the Grantor's Death Certificate to:

 Missouri Beneficiary Deed c/o

 Michael J. Denk, Attorney at Law

 P.O. Box 6464, Chesterfield, MO 63006

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 Affidavit As To Death of Grantor

Request Form

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Grantor Name as set forth in Beneficiary Deed (send copy of Beneficiary Deed):

______________________________________________________________________

Date of Death of Grantor (send copy of Death Certificate):

______________________________________________________________________

______________________________________________________________________

Grantee(s)/Beneficiary(ies) Name(s) as set forth in Beneficiary Deed:

________________________________________________________________

________________________________________________________________

________________________________________________________________

________________________________________________________________

Grantee Mailing Address (address for one Grantee, no P.O. Boxes):

_________________________________________________________________

_________________________________________________________________

Missouri County Where Real Property is Located:

_________________________________________________________________

Missouri City Where Real Property is Located:

_________________________________________________________________

Address of Real Property:

_________________________________________________________________

_________________________________________________________________

.

Your Full Name:

________________________________________________________________

Your Relationship to the Grantor: __________________

Your Mailing Address:

_______________________________________________________________

_______________________________________________________________

Your Telephone Number:

_______________________________________________________

Your Signature:

_______________________________________________________

.

By signing above you agree this form will serve as the written agreement between yourself and Michael J. Denk, Attorney at Law, to draft and provide you with one (1) Affidavit per your request and information as set forth on this form. The cost is $100.00 per affidavit. The filing/recording of your Affidavit and the filing fee as charged by the appropriate Recorder of Deeds office will be your responsibility. You understand and agree no legal advice is being provided to you and you should consult with an Attorney of your choice for such advice. You hereby release Michael J. Denk and Missouri Beneficiary Deed, LLC from any and all claims relating to your use of such Affidavit. If you have any questions or concerns please contact us prior to signing and returning this form. Thank you.

Fill in all information on this form and then mail with (i) payment, (ii) a copy of the current Beneficiary Deed, and (iii) a copy of the Grantor's Death Certificate to:

 Missouri Beneficiary Deed c/o

 Michael J. Denk, Attorney at Law

 P.O. Box 6464, Chesterfield, MO 63006

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