SURROGATE'S COURT, QUEENS COUNTY In the Matter of the Application to examine a Safe Deposit Box of File No. Petition to Examine Safe Deposit Box Deceased. TO THE SURROGATE'S COURT OF THE COUNTY OF QUEENS: The petition of of the deceased, and resides at respectfully shows that he/she is That the said on deceased, died at a resident of , in the County of Queens and State of New York. That the said deceased has a safe deposit box in the vault of a corporation doing business in the County of Queens and State of New York. That the names, residence addresses and relationship of the distributees of the decedent are as follows: Relationship Name Residence Your petitioner believes that said deceased may have left one or more of the following papers or instruments in said safe deposit box, to wit, a will of said deceased, a policy or policies of insurance issued in the name of said decedent and payable to a named beneficiary or beneficiaries and a deed to a burial plot in which said decedent is to be interred. -1- P-15-O(2/11) American LegalNet, Inc. www.FormsWorkFlow.com WHEREFORE your petitioner prays that an order be made permitting the petitioner, or agent of the petitioner, to examine the said safe deposit box in the presence of an officer of said corporation for the purpose of ascertaining if any of said papers or instruments be deposited therein, and if a will of said deceased be found the same be delivered to the clerk of this court; if such policy or policies of insurance be found that they be delivered to the beneficiary or beneficiaries named therein, and if a deed to such burial plot be found that the same be delivered to your petitioner, or agent of the petitioner, and that your petitioner, or agent of the petitioner, be permitted to make a copy of any paper or papers found in said box bearing upon the desire of the said deceased as to the disposal of his/her remains, and your petitioner further prays that; he/she or the agent of your petitioner, be permitted to make an inventory of the contents of said box in order to fix the amount of the bond to be given on an application for letters of administration. Dated: Petitioner STATE OF NEW YORK COUNTY OF } being duly sworn, says that he/she is the petitioner named in the foregoing petition, that he/she has read the foregoing petition subscribed by him/her and knows the contents thereof; and that the same is true of his/her own knowledge, except as to the matters therein stated to be alleged on information and belief, and that as to those matters he/she believes it to be true. Sworn to before me this day of Petitioner Notary Public, State of N.Y. Attorney Address Phone No. ( ) - P-15-O(2/11) -2American LegalNet, Inc. www.FormsWorkFlow.com