JDF 898 SC R 6 /1 9 PUBLIC STATEMENT OF ACCOUNT PURSUANT TO SMALL ESTATE PROCEDURE Page 1 of 3 District Court Denver Probate Court County, Colorado Court Address: In the Matter of the Estate of: Deceased COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E - mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom PURSUANT TO SMALL ESTATE PROCEDURE Pursuant to section 15 - 12 - 621(6), C.R.S. a ll estates administered by a public administrator pursuant to the small estate procedure shall be closed by the filing of a public administrator's statement of account with the appointing district or probate court. The statement of account shall set forth all receipts and disbursements made during the administration of the estate including the public administrator's fees and costs, and the fees and costs of the public administrat or's staff and investigators. Upon filing of the public administrator's statement of account and all fee statements , the public administrator shall be discharged and released from all further responsibility and all liability with regards to the estate. CO MES NOW, , the Public Administrator/Deputy Public Administrator for the Judicial District hereby states as follows: 1. That the Estate of , decedent, is a small estate as defined in C.R.S. 15 - 12 - 1201, as amended. 2. That the decedent died on . 3. The claims period for the claims against the estate ended on . 4. That a f iling fee of accompanies this statement as the gross assets of this Estate are: more than $500.00 but less than $2,000.00 or more than $2,000.00. ITEMS OF RECEIPT (Detail Listing and/or Attached Ledger) Description Receipt Value 1 2 3 TOTAL RECEIPTS A SSET DESCRIPTION OF ASSETS DONATED OR DISPOSED OF Collecti bles Clothing Household Items American LegalNet, Inc. www.FormsWorkFlow.com JDF 898 SC R 6 /1 9 PUBLIC STATEMENT OF ACCOUNT PURSUANT TO SMALL ESTATE PROCEDURE Page 2 of 3 Miscellaneous Items Other PUBLIC ADMINISTRATOR/DEPUTY PUBLIC ADMINISTRATOR FEES & COSTS (INCLUDING PUBLIC ADMINISTRATOR STAFF/INVESTIGATOR FEES), AND ESTATE EXPENSES/CLAIMS PAID (ATTACH ALL FEES/COSTS STATEMENTS) Description Amount Paid 1 2 TOTAL FEES, COSTS & EXPENSES/CLAIMS PAID DISTRIBUTIONS TO HEIRS/DEVISEES AND FUNDS PAID TO THE COLORADO DEPARTMENT OF THE TREASURY First and Last Name of Recipient /Dept. of the Treasury Funds Distributed 1 2 3 T OTAL FUNDS DISTRIBUTED PUBLIC ADMINISTRATOR LOSS SUMMARY ( Unpaid Fees/Costs and/ or Attach Ledger) Loss of PA Fees Loss of PA Costs Loss of PA Staff/Investigator Fees Effective Rate Total Fees/Costs Lost TOTALS & GRAND TOTAL OF FEES/COST LOST By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. By checking this box, I am acknowledging that I have made a change to the original content of this form. I understand that this Statement is subject to audit and verification. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the day of , , (date) (month) (year) at ( city or other location, and state OR country) (printed name) (signature) American LegalNet, Inc. www.FormsWorkFlow.com JDF 898 SC R 6 /1 9 PUBLIC STATEMENT OF ACCOUNT PURSUANT TO SMALL ESTATE PROCEDURE Page 3 of 3 Note: Public Administrators must attach their detailed fees/costs account statement to this form. Public Administrators must file this form with the court at the closing of the small estate. American LegalNet, Inc. www.FormsWorkFlow.com