GOVERNMENT OF THE UNITED STATES VIRGIN ISLANDS 
OFFICE OF THE LIEUTENANT GOVERNOR 
DIVISION OF BANKING, INSURANCE AND FINANCIAL REGULATION 
 
5049 Kongens Gade, St. Thomas, VI 00802-6487 • Tel: 340-774-7166 • Fax: 340-774-9458 
1131 King Street, Suite 101, Christiansted, VI 00820 • Tel: 340-773-6459 • Fax: 340-719-3801 
AFFIDAVIT  
 
PAYMENT OF CERTAIN DEBTS WITHOUT ADMINISTRATION 
Pursuant to Section 89, Title 15 of the Virgin Islands Code 
 
 
I/WE, ___________________________________, after being first duly sworn, depose and state 
that: 
 
1. 
Name of the decedent:  _________________________________________________ 
2. 
The date of death of the decedent: _________________________________________ 
3. 
The relationship of the affiant to the decedent:  ______________________________ 
4. 
That no executor or administrator has qualified or been appointed; 
5. 
The names and addresses of the persons entitled to and who will receive the money 
paid; and 
Name:___________________________ Name:______________________________ 
Address: _________________________ Address: ____________________________ 
 
         _________________________  
    ____________________________ 
 
         _________________________  
    ____________________________ 
 
 
6. 
That such payment and all other payments made, by all debtors, known to the affiant, 
after diligent inquiry, do not in the aggregate exceed such amount of $10,000 as 
provided by regulation promulgated by the Lieutenant Governor of the Virgin Islands. 
 
 
___________________________________  
Date: ________________________ 
Claimant’s Signature 
 
 
Subscribed and Sworn to before me this _____ day of _____________________, 20______. 
 
 
____________________________________ 
Notary Public 
 
 
 
 
 
 
           NP#__________________ 
 
 
 
 
 
 
 
Expires:_______________