IN THE DISTRICT COURT FOR THE STATE OF ALASKA AT ) ) ) ) ) ) ) ) ) In The Matter of: CASE NO. APPLICATION FOR APPOINTMENT AS TEMPORARY PROPERTY CUSTODIAN UNDER AS 22.15.110(a)(3) Deceased I, , request appointment as temporary custodian of the property of the decedent under AS 22.15.110(a)(3). I swear or affirm under penalty of perjury that the following information is true: 1. 2. 3. 4. 5. 6. 7. 8. Date of decedent's death Decedent's domicile (legal residence) at the time of death My mailing address is My physical address is My telephone number is My employer is My date of birth is My driver's license number is or my state identification number is or my passport number is 9. My relationship to the decedent was: (check all that apply) We were related by blood or marriage as follows: We were friends acquaintances co-workers business associates State State Country employer-employee We shared a household Other (explain) Page 1 of 2 P-130 (5/12)(cs) Application For Appointment Under AS 22.15.110(a)(3) AS 22.15.110(a)(3) Probate Rule 9.1(b) American LegalNet, Inc. www.FormsWorkFlow.com 10. The relatives of the decedent that I know of are: Name Address Relationship to Decedent 11. I agree to take temporary custody of and preserve the following property of the decedent: Description of Property Currently Located at or Held By Location Where the Property Will Be Taken Additional pages are attached: pages. Unless otherwise ordered by the court, I agree to turn over the property to the personal representative of the decedent's estate, if one is appointed, or to the person(s) designated to receive it in the decedent's will (if there is one), or to the decedent's heirs. Date Subscribed and sworn to or affirmed before me at on . (date) (SEAL) Signature of Applicant , Alaska, Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: 1. original to district court 2. copy to applicant AS 22.15.110(a)(3) Probate Rule 9.1(b) American LegalNet, Inc. www.FormsWorkFlow.com Distribution: Page 2 of 2 P-130 (5/12)(cs) Application For Appointment Under AS 22.15.110(a)(3)