ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address) FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN LUIS OBISPO STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: 1035 Palm Street, Room 385 Same as above San Luis Obispo, CA 93408 San Luis Obispo CASE NUMBER: ESTATE OF: Hearing Date: Time: Department: FIRST AND FINAL REPORT OF PERSONAL REPRESENTATIVE AND PETITION FOR FINAL DISTRIBUTION ON (Check one box): WAIVER OF ACCOUNT; OR ACCOUNT AND FOR PAYMENT OF COMPENSATION FOR ORDINARY AND/OR EXTRAORDINARY SERVICES TO (Check one or both): PERSONAL REPRESENTATIVE ATTORNEY FOR PERSONAL REPRESENTATIVE (Probate Code Sections 10831, 10951, 10954, 11640, et seq) Petitioner(s) (name(s)):_________________________________________________________________________ allege(s): 1. Decedent (name):_______________________________________________________________________________ died testate intestate on (date):____________________________________________ at (place):__________________________________________________________being a resident of the County of San Luis Obispo, State of California, at the time of his or her death. 2. Will dated _____________________ and codicil dated _________________. was/were admitted to Probate by order of this Court on (date):___________. Petitioner qualified as Executor Administrator Administrator with Will Annexed and Letters were issued to Petitioner on (date):_______________. At all times since then, Petitioner has been, and now is, duly qualified as the Personal Representative of Decedent's Estate. On ______________by order of this Court, Petitioner was authorized to administer the estate under the Independent Administration of Estates Act with full OR limited authority. This authority has not been revoked. Notice of Petition to Administer Estate has been published for the period and in the manner as prescribed by law, and within thirty (30) days after completion of the publication there was filed with the Clerk of this Court an affidavit showing the publication in the manner and form required by law. Page 1 of 8 Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR006 Rev. 8/31/12 3. 4. 5. FIRST AND FINAL REPORT OF PERSONAL REPRESENTATIVE; PETITION FOR FINAL DISTRIBUTION AND FOR PAYMENT OF COMPENSATION Statutory Authority Probate Code §§10831, 10951, 10954,11640, et seq American LegalNet, Inc. www.FormsWorkFlow.com ESTATE OF: CASE NUMBER: 6. More than four (4) months have elapsed since the issuance of Letters. Reasonable efforts were made to identify creditors of the estate and Notice of Administration has has not been sent to all known creditors of the estate. The time for filing and presenting creditor's claims has expired. Notice was mailed to the Franchise Tax Board on (date):_______________________. (Prob. Code, § 9202, subd. (c).) a. The decedent did not own a business at the time of his or her death. Petitioner has no reason to believe that the State Board of Equalization (BOE) has any basis for making a claim against the estate for unpaid taxes related to retail sales or sales of cigarettes, motor vehicle fuel or alcoholic beverages. Petitioner has no reason to believe that the Employment Development Department (EDD) has a claim for unpaid unemployment insurance. (Prob. Code, § 9201.) Notice was served on the BOE on (date): ________________ and on the EDD on (date): _________________ . b. Neither the decedent nor his or her spouse, father, mother nor child was a patient in a state institution under the jurisdiction of the California Department of Mental Health (DMH). Petitioner has no reason to believe the Department of Mental Health has any basis for making a claim against the estate. Notice was served on the DMH on (date): _______________________. c. The decedent did not receive and was not the surviving spouse or registered domestic partner of a person who received Medi-Cal benefits. Petitioner has no reason to believe the Department of Health Services (DHS) has a claim against the estate. Notice was served on the DHS on (date):____________________ with a copy of Decedent's death certificate and with a copy of the death certificate of the decedent's pre-deceased spouse or registered domestic partner (name) (Prob. Code, § 9202, subd. (a).):_________________________________. d. Petitioner knows of no heir that is confined in a prison or facility under the jurisdiction of the Department of Corrections or the Department of Youth Authority or confined in any county jail, road camp, industrial farm or other local correctional facility. Therefore, notice is not required to be given to the Director of the California Victim Compensation and Government Claims Board. (Prob. Code, § 9202, subd. (b).) Notice was served on the California Victim Compensation and Government Claims Board on (date): (Prob. Code, § 9202, subd. (b).) 7. 8. OR OR OR OR 9. No requests for special notice have been filed in this proceeding. OR The following requests for special notice have been filed in this proceeding: Name Date Filed Relationship Continued in Attachment 9. Page 2 of 8 Form Adopted for Optional Use San Luis Obispo Superior Court Local Form PR006 Rev. 8/31/12 FIRST AND FINAL REPORT OF PERSONAL REPRESENTATIVE; PETITION FOR FINAL DISTRIBUTION AND FOR PAYMENT OF COMPENSATION Statutory Authority Probate Code §§10831, 10951, 10954,11640, et seq American LegalNet, Inc. www.FormsWorkFlow.com ESTATE OF: CASE NUMBER: 10. Petitioner has performed all required duties as Personal Representative of the Estate. All costs of administration incurred to date, including costs of publication and the probate referee's fees, have been paid and the estate is now in a condition to be closed. The following Inventory and Appraisal(s) have been filed with the court: Date Filed Partial No. Partial No. Partial No. Continued in Attachment 11. Final Final Final Type Supplemental Supplemental Supplemental Amount Corrected/Amended Corrected/Amended Corrected/Amended 11. 12. The estate consists community property. entirely of OR of a combination of Decedent's separate community quasi- 13. Petitioner alleges that no family or affiliate relationship exists between Petitioner and any agent hired by Petitioner during the period of administration. OR The following family or affiliates were hired: Name Capacity Retained Relationship Continued in Attachment 13. 14.