Form 17.

[Caption]

INVENTORY OF DECEDENT'S ESTATE

The undersigned, ___________ of the estate of ___________, deceased, states on oath that to the best of my knowledge and belief, the following is a complete and accurate inventory of all property owned by the decedent, and its fair market value, at the time of the decedent's death.

REAL ESTATE

Legal Encumbrances, Liens, etc., and Net Value

Description Respective Amounts Thereof

Homestead: ____________ ______________________________ $ ______

Other real estate: ____________ ______________________________ $ ______

Total Value of Real Estate: $ ________

PERSONAL PROPERTY

Household Goods and Personal Effects

[This list should include, but not be limited to, furniture, household and yard equipment, clothing, jewelry, etc.]

Description Encumbrances, Liens, etc., and Net Value

Respective Amounts Thereof

___________ _______________________________ $________

___________ _______________________________ $ ________

Other Tangible Personal Property

[This list should include, but not be limited to, automobiles and other motor

vehicles, farm equipment, livestock, agricultural products, stocks of merchandise, any going business enterprise or interest therein, etc.]

Description Encumbrances, Liens, etc., and Net Value

Respective Amounts Thereof

___________ ________________________________ $ ________

___________ ________________________________ $ ________

Intangible Personal Property

[List separately in detail: cash on hand; money on deposit, stating names and addresses of depositories; bonds, stating names of issuers, interest rates, classes, maturity dates, serial numbers, face amounts, and dates to which interest is paid; corporate stocks, stating certificate numbers, names of issuers, classes, and number of shares; notes receivable, stating the names and addresses of makers, dates, amounts, interest rates, and dates to which interest paid, balances due, maturities, and security, if any; accounts receivable, stating names of debtors,dates of last items and balances due; and other intangibles, describing in detail.]

 

Description Encumbrances, Liens, etc., and Net Value

Respective Amounts Thereof

____________ _______________________________ $ ________

____________ _______________________________ $ ________

Total Value of Personal Property: $ ________

SUMMARY

Total real property: $ ________

Total personal property: $ ________

Total estate: $ ________

The undersigned was not indebted or obligated to the decedent at the time of the decedent's death except as stated herein.

Date: ________, ____.

________________________________

[Signature]

[Affidavit]

Reporters Notes to Form 17: See Ark. Code Ann. 28-49-110.This form should be filed by the personal representative within two months after qualification, unless the requirement is waived pursuant to Ark. Code Ann. 28-49-110(c)(1). Inventory should not include any property owned jointly with right of survivorship by the decedent and a third party, or any insurance proceeds or other benefits payable by beneficiary designation, unless such benefits are payable to the decedent's estate. An affidavit is required by Ark. Code Ann. 28-49-110(a)(2).