SURROGATE'S COURT OF THE STATE OF NEW YORK COUNTY OF _________________________ ---------------------------------------------------------------------------X VOLUNTARY ADMINISTRATION, Estate of ____________________________________ , Deceased. -------------------------------------------------------------------------- X STATE OF NEW YORK COUNTY OF ) ) ss.: ) AM ENDED AFFIDAVIT IN RELATION TO SETTLEM ENT OF ESTATE UNDER ARTICLE 13, SCPA (as of 1/2009) File No._________________________ I, _________________________________________, being duly sworn, depose and say: (Nam e) 1. I am the voluntary adm inistrator/trix of the above-nam ed decedent and m ake this affidavit pursuant to Article 13 of the Surrogate's Court Procedure Act. The original and any am ended affidavits were filed on the following dates: [list dates] 2. I was found qualified to act as the voluntary adm inistrator/trix of the above captioned estate by the ________________________County Surrogate's Court on the __________ day of __________, 20 ________. 3. The following item s of personal property, owned by the above-nam ed decedent, were not listed in paragraph 9 of the Affidavit of Voluntary Adm inistration originally filed nor in any am ended affidavits filed with the court. Items of Personal Property Separately Listed ______________________________ ______________________________ Value of Each Item ____________________________________ ____________________________________ Total $ ____________________ 4. For the item of personal property listed in paragraph 3, I require _______________________ additional certificates of voluntary adm inistration. The value of all of the decedent's non-exem pt assets still does not exceed $30,000.00. ___________________________________ (Affiant) ___________________________________ (Print Nam e) _________________________________ Notary Public My Com m ission Expires: (Affix Notary Stam p or Seal) Sworn to be fore m e on _______________, 20 ______ Signature of Attorney :_______________________________________________________________________________ Print Nam e:________________________________________________________________________________________ Firm Nam e:_________________________________________ Tel No. : _______________________________________ Address of Attorney:_________________________________________________________________________________ SE-3B *For use only where decedent died on or after January 1, 2009 American LegalNet, Inc. www.FormsWorkflow.com SE-3B