11/30/2016 Form 17 Inventory of Decedent's Estate Form 17. [Caption] INVENTORY OF DECEDENT'S ESTATE The undersigned, ___________ of the estate of ___________, deceased, states on oath that to the best of my knowledge and belief, the following is a complete and accurate inventory of all property owned by the decedent, and its fair market value, at the time of the decedent's death. REAL ESTATE Legal Encumbrances, Liens, etc., and Net Value Description Respective Amounts Thereof Homestead: ____________ ______________________________ $ ______ Other real estate: ____________ ______________________________ $ ______ Total Value of Real Estate: $ ________ PERSONAL PROPERTY Household Goods and Personal Effects [This list should include, but not be limited to, furniture, household and yard equipment, clothing, jewelry, etc.] Description Encumbrances, Liens, etc., and Net Value Respective Amounts Thereof ___________ _______________________________ $________ ___________ _______________________________ $ ________ Other Tangible Personal Property [This list should include, but not be limited to, automobiles and other motor vehicles, farm equipment, livestock, agricultural products, stocks of merchandise, any going business enterprise or interest therein, etc.] Description Encumbrances, Liens, etc., and Net Value Respective Amounts Thereof ___________ ________________________________ $ ________ ___________ ________________________________ $ ________ Intangible Personal Property https://courts.arkansas.gov/system/files/form17.html American LegalNet, Inc. www.FormsWorkFlow.com 1/2 11/30/2016 Form 17 Inventory of Decedent's Estate [List separately in detail: cash on hand money on deposit, stating names and addresses of depositories bonds, stating names of issuers, interest rates, classes, maturity dates, serial numbers, face amounts, and dates to which interest is paid corporate stocks, stating certificate numbers, names of issuers, classes, and number of shares notes receivable, stating the names and addresses of makers, dates, amounts, interest rates, and dates to which interest paid, balances due, maturities, and security, if any accounts receivable, stating names of debtors,dates of last items and balances due and other intangibles, describing in detail.] Description Encumbrances, Liens, etc., and Net Value Respective Amounts Thereof ____________ _______________________________ $ ________ ____________ _______________________________ $ ________ Total Value of Personal Property: $ ________ SUMMARY Total real property: $ ________ Total personal property: $ ________ Total estate: $ ________ The undersigned was not indebted or obligated to the decedent at the time of the decedent's death except as stated herein. Date: ________, ____. ________________________________ [Signature] [Affidavit] Reporters Notes to Form 17: See Ark. Code Ann. � 2849110.This form should be filed by the personal representative within two months after qualification, unless the requirement is waived pursuant to Ark. Code Ann. � 2849110(c)(1). Inventory should not include any property owned jointly with right of survivorship by the decedent and a third party, or any insurance proceeds or other benefits payable by beneficiary designation, unless such benefits are payable to the decedent's estate. An affidavit is required by Ark. Code Ann. � 2849110(a)(2). https://courts.arkansas.gov/system/files/form17.html American LegalNet, Inc. www.FormsWorkFlow.com 2/2