Financial Report Decedent's Estate PC-246 NEW 7/13 RECEIVED: C O N N E C T I C U T P R O B A T E C O U R T S RECORDED: Instructions: 1) A fiduciary may use this financial report instead of filing a final account for a decedent's estate unless: (a) the court has ordered the fiduciary to file an account; or (b) an account is required under the Probate Court Rules of Procedure, section 36.3. 2) Type or print the form in ink. 3) Attach supporting schedules if necessary to provide additional details or explanatory notes. 4) The fiduciary shall send a copy of this financial report to each party and attorney. 5) For further information, see the Probate Court Rules of Procedure, sections 37.1 and 37.4. District Number Probate Court Name Estate of Fiduciary (List name, address and telephone number of each fiduciary.) EACH FIDUCIARY WHO SIGNS THIS FINANCIAL REPORT REPRESENTS UNDER PENALTIES OF FALSE STATEMENT THAT: 1) The fiduciary has retained all supporting records for this financial report as required by the Probate Court Rules of Procedure, section 36.13, and the records are available for review on request. 2) All funeral expenses, taxes, expenses of administration and claims of creditors are shown below and have been paid. 3) All distributions listed below have been or will be distributed. 4) The following is a true and complete summary of the assets of the estate and the fiduciary's receipts, payments and distributions: Assets and Income Received Total amount reported on the inventory Total amount of additional assets received Income received: Interest Dividends Rent Other (Specify and attach second sheet if necessary.) Net amount of capital gain (or loss) on the sale of assets If real property has been sold, attach copy of settlement statement from closing. Cash advanced to the estate by _________________ to pay claims and expenses Indicate if there is an expectation of reimbursement: Yes No Total $ $ $ $ $ $ $ $ $ PC-246 NEW 7/13 PAGE Financial Report Decedent's Estate 1/4 Financial Report Decedent's Estate PC-246 NEW 7/13 C O N N E C T I C U T P R O B A T E C O U R T S RECORDED: Payments Funeral Expenses Administration Expenses: Fiduciary fees Fiduciary disbursements Attorney's fees Attorney's disbursements Accounting expenses Probate court fees and expenses Probate bond premium Publication of notices Other expenses (Specify and attach second sheet if necessary.) Taxes: Town of Property Tax State of Connecticut Income Tax Estate Tax Internal Revenue Service Income Tax Estate Tax Total amount of claims as reported on PC-237, Return of Claims and List of Notified Creditors Total $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Distributions Except as provided in section 37.4 of the Probate Court Rules of Procedure, distributions must be itemized and listed at fair market value on the date of distribution. Attach second sheet if necessary. Distributions Already Made as of the Date of this Financial Report Name of Distributee If decedent had a will, specify section providing for distribution Assets Distributed Fair Market Value $ $ $ Subtotal $ $ $ $ Subtotal $ $ $ $ Subtotal $ Total $ PC-246 NEW 7/13 PAGE Financial Report Decedent's Estate / Financial Report Decedent's Estate PC-246 NEW 7/13 C O N N E C T I C U T P R O B A T E C O U R T S RECORDED: Proposed Distributions Name of Distributee If decedent had a will, specify section providing for distribution Assets to be Distributed Fair Market Value $ $ $ Subtotal $ $ $ $ Subtotal $ $ $ $ Subtotal $ $ $ $ Subtotal $ $ $ $ Subtotal $ Total $ Reserve (if any) Assets Fair Market Value $ $ Total $ EACH FIDUCIARY REQUESTS: (1) approval of this financial report; (2) approval of any proposed distribution shown above; and (3) release from liability, pursuant to C.G.S. § 45a-176, with respect to all items shown in this financial report. The fiduciary requests the issuance of a certificate to record the distribution of real property on the land records. The representations contained in this financial report are made under the penalties of false statement. Signature of Fiduciary Type or Print Name Date Signature of Fiduciary Type or Print Name Date Financial Report Decedent's Estate PC-246 NEW 7/13 PAGE / Financial Report Decedent's Estate PC-246 NEW 7/13 C O N N E C T I C U T P R O B A T E C O U R T S RECORDED: Certification I certify that a copy of this financial report was sent to the following persons: Name and Address Signature of fiduciary or attorney ___________________________________________________________________ Type or Print Name: ____________________________________________________________________________________ Date: ________________________________________________________________________________________________ Financial Report Decedent's Estate PC-246 NEW 7/13 PAGE /