IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Estate of: ) ) ) ) ) ) ) ) ) Person Who Died (Decedent) Date of Birth: CASE NO. SWORN STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE 1. 2. Personal Representative. I am the personal representative of this estate. Estate Value. To the best of my knowledge, the value of the entire estate, after subtracting liens and debts, is not more than the combined total of the following: � homestead allowance; � exempt property; � family allowance; � costs and expenses of administration; � reasonable funeral expenses; � reasonable and necessary medical and hospital expenses of the decedent's last illness. Duties. I performed the following duties [you must do all of the following]: Distributed the assets of the estate to the persons entitled. Sent a copy of this document to all persons or creditors who received estate property, and to all interested persons whose claims were unpaid. Sent an accounting to all persons who received estate property or whose interests are affected. [If individuals waived their right to receive an accounting, you must file the waivers with this document.] 3. 4. Closing Statement. I am filing this statement to close this estate. I understand that my appointment as personal representative will end in one year as long as no action or proceeding involving me as personal representative is pending in the court. I will remain the personal representative until that time. Signature of Personal Representative Printed Name Date Address Line 1 Address Line 2 Phone Number E-mail Address Page 1 of 2 AS 13.16.690, AS 13.16.695 P-350 (7/14)(cs) SWORN STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE American LegalNet, Inc. www.FormsWorkFlow.com Verification I swear or affirm that I read this entire document and believe that all of the statements made in the document are true. Personal Representative's Signature Subscribed and sworn to or affirmed before me at on (SEAL) (date) . Clerk of Court, Notary Public, or other person authorized to administer oaths. My commission expires: Certificate of Service [A copy of this Statement and a copy of the accounting must be given to all persons who received something in the estate or had claims against the estate.] I certify that on a copy of this Statement was [list everyone served and attach extra pages if necessary]: mailed hand delivered to , Alaska Your signature: Page 2 of 2 AS 13.16.690, AS 13.16.695 P-350 (7/14)(cs) SWORN STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE American LegalNet, Inc. www.FormsWorkFlow.com