SURROGATES COURT OF THE STATE OF NEW YORK COUNTY OF VOLUNTARY ADMINISTRATION, Estate of REPORT AND ACCOUNT IN SETTLEMENT OF ESTATE PURSUANT TO ARTICLE 13, SPCA (as of 6/91) , Deceased. File No. The undersigned, authorized by this court to act as the voluntary administrator of the above entitled estate,reports and accounts as follows: 1. There has come into my possession the following personal property of the deceased, which is on hand or hasbeen converted into cash in the amounts indicated: Item Value _________________________________ ________________________ _______________________________ ___________________________________________________________________ ___________________________________________________________ __________ _________________________________________ [If more space is needed add a sheet of paper] Total value of personal property and cash: $ ____________________________________________________ 2. All of this personal property and cash have been disbursed or distributed as follows: Item or Cash To Whom __________________________ ________________________ ______________________________________ ____________________________________________________________ ____________________________________________________________________________________________________________________ Receipts of canceled checks showing the payment of expens es of administration, disbursements, or distributionsare annexed. 3. No Part of the estate of the decedent remains in my possession. Voluntary Administrator/rix Print Name of Voluntary Administrator/rixSTATE OF NEW YORK ) ) ss.: COUNTY OF ) ________________________________________, being duly sworn, deposes and says: I have read the foregoing Report and Account and know the contents thereof; the matters and things therein stated are trueof my own knowledge; the foregoing Account is in all respects just and true and contains a full, particular and true account ofall money and property of the deceased coming into my possession; and the administration expenses, disbursements anddistribution shown have been actually made for the purposes and reasons therein stated. _____________________________Sworn to before me on (Affiant)_______________________, 20 ____ ______________________________ Notary Public My Commission expires: __________ SE-1D