Estate of First, middle, and last name , decedent Last four digits of SSN I, Name and relationship , represent that: 1. þ Decedent died on Date . 2. þ þ Decedent was a resident of City/Township þ þ Decedent lived outside of Michigan and left an estate within this county to be administered. 3. þ The decedent222s personal and real property, gross values, and lien amounts (if any) are listed below. The values of all property þ are calculated as of the decedent222s date of death. *For real property only, if the date of death is on or after March 28, 2013, þ the gross value of a parcel can be reduced by any lien amount on that parcel; however the remaining inventory value of that þ parcel cannot be less than zero. For personal property, the gross value and inventory value are the same. þ(Attach separate sheet if necessary.) Legal description of real propertyGross valueLien amountInventory value (less lien)*Legal description of real propertyGross valueLien amountInventory value (less lien)*Description of personal propertyGross valueInventory valueDescription of personal propertyGross valueInventory valueDescription of personal propertyGross valueInventory valueDescription of personal propertyGross valueInventory valueTotalsTotal Gross ValueTotal Inventory Value 4. þFuneral and burial expenses are $ . þ The following persons have paid the following amounts toward the funeral and burial expenses: (Statements and receipts are attached.) NAMEAMOUNTNAMEAMOUNT þ þ The amount of funeral and burial expenses remaining unpaid is $ . þ The gross value of the decedent222s property remaining after payment of funeral and burial expenses does not/will not þ exceed þ $15,000 as adjusted annually for cost of living. PETITION XXX-XX- American LegalNet, Inc. www.FormsWorkFlow.com File No. 5. þ The name and address of the surviving spouse or, if there is not a spouse, the name, age, relationship, and address of þ each of the decedent222s heirs are as follows: NAMEAGERELATIONSHIPADDRESSStreet addressCityStateZipStreet addressCityStateZip 6. þ I REQUEST that the property listed above be assigned as follows: þ þ a. þ for funeral and burial expenses, $ to Name , $ þ to Name , and $ to Name . þ þ b. þ to the surviving spouse, . þ þ c. þ to the following heirs in the stated proportions, þ .I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. Attorney signature þ Date Name (type or print) Bar no. þ Petitioner signature Address þ Address City, state, zip Telephone no. þ City, state, zip Telephone no. IT IS ORDERED: þ 7. þ The property described above is assigned as follows: þ þ a. þ for funeral and burial expenses, $ to Name , $ þ to Name , and $ to Name . þ þ b. þ to the surviving spouse, . þ þ c. þ to the following heirs in the stated proportions, þ . þ For 63 days from the date of this order, the share of each heir other than a surviving spouse or minor child þ shall be subject to any unsatisfied debt of the decedent up to the value of property received through this order. þ 8. þ The petition is þ denied. þ dismissed/withdrawn. þ Date þ Judge Bar no. I certify that I have compared this copy with the original on file and that it is a correct copy of the original. Date þ Deputy register ORDER ASSIGNING ASSETS American LegalNet, Inc. www.FormsWorkFlow.com