SURROGATE COURT OF SUSSEX COUNTY GARY R. CHIUSANO, SURROGATE 3 High Street, Suite 1, Newton, New Jersey 07860 Office: (973) 579-0920 Website: http://www.sussexcountysurrogate.com/ Fax: (973) 579-0909 E-mail: surrogate@sussex.nj.us ESTATE OF:____________________________________________ D.O.D.:__________________ AKA:___________________________________AGE:____________SS#:_____________________ RESIDENT MUNICIPALITY:_____________________________________ D.O.WILL:___________________ D.O.CODICIL:____________________ D.O. PROBATE OF WILL:________________________________________ INDEX #:__________________ IDENTIFY PARAGRAPH IN WILL DESIGNATING TRUSTEE:_________________________ FIDUCIARY: {ESQ-yes/no} Trustee NAME: _______________________________________________SS#: ________________________ ADDRESS: _________________________________________________________________________ HOME PHONE #:_________________________ WORK PHONE #:__________________________ FAX #: __________________________________ CELL #:___________________________________ PERSON(S) WHO STAND TO BENEFIT FROM TRUST: NAME: FULL ADDRESS: RELATION: AGE: _______________________________ _________________________________ ______________ ______ _______________________________ _________________________________ ______________ ______ _______________________________ _________________________________ ______________ ______ IDENTIFY INTEREST IN WILL, PARAGRAPH #_________________ OUTLINE INTEREST:___________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ _________________________________________________________________________________ ATTORNEY:________________________________________________ ADDRESS:__________________________________________________ _____________________________________________________ PHONE:_______________________FAX:_________________________ OFFICE USE ONLY DATE:____________________INITIAL:________PREV. IND.: No________YES #______________ MAIL TO:__________________________________ OBIT: YES / NO SURROGATE CERTIFICATES: #______________ INFO FOLDERS: YES / NO SURETY/PERSONAL BOND: $________________ FEE: $___________________ BOND #___________________ PAID:_____________CK/ CASH/CHG VALUE OF ESTATE: $_______________________ DOP:_____________________________ FILL IN ALL OF ABOVE; THEN FAX OR MAIL OR E-MAIL; CALL FOR APPOINTMENT. THANK YOU! Rev. 7/13 American LegalNet, Inc. www.FormsWorkFlow.com