JDF 965 SC R 6 /1 9 STATEMENT OF PERSONAL REPRESENTATIVE CLOSING ADMINISTRATION Page 1 of 2 District Court Denver Probate Court County, Colorado Court Address: I n 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 STATEMENT OF PERSONAL REPRESENTATIVE CLOSING ADMINISTRATION PURSUANT TO 24715 - 12 - 1003, C.R.S. I, ( p e rsonal r epresentative ) , state the following : 1. Six months have passed since the original appointment of a general p ersonal r epresentative for this estate or at least one year has passed since the d 2. The date of the original appointment was . 3. Except as may be disclosed on an attached explanation, the undersigned or a pr ior p ersonal r epresentative has fully administered this es tate by making payment, settlement , or other disposition of: all lawful claims; expenses of administration; federal and state estate taxes ; inheritance taxes and other death taxes; and the d persons entitled to receive such assets in the amount and in the manner to which they were entitled. If any claims are listed on an attached explanat ion as remaining undischarged, the explanation states whether the distributions were made subject to possible liability with the agreement of the distributees or must state in detail other arrangements to accommodate outstanding liabilities. 4. The undersi gned has sent a copy of this s tatement to all distributees of this estate and to all creditors or other claimants whose claims are neither paid nor barred, and has furnished a full account in writing of the whose interests are affected. 5. No c ourt order prohibits the informal closing of this estate. Administration of this estate is not supervised. This s tatement is filed for the purpose of closing this estate. The appointment of the p ersonal r epresentativ e will terminate one year after this s tatement is filed with the c ourt if no proceedings involving the undersigned are then pending . 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. American LegalNet, Inc. www.FormsWorkFlow.com JDF 965 SC R 6 /1 9 STATEMENT OF PERSONAL REPRESENTATIVE CLOSING ADMINISTRATION Page 2 of 2 VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the day of Executed on the day of (date) (date) , , , , (month) (year) (month) (year) at at (city or other location, and state OR country) (city or other location, and state OR country) (printed name) (printed name) (Signature of Personal Representative ) (Signature of Co - Personal Representative , if any) CERTIFICATE OF SERVICE I certify that on (date), a copy of this (name of document) was served as follows on each of the following: Name and Address Relationship to Decedent, Ward, or Protected Person Manner of Service* *Insert one of the following: hand delivery, first - class mail, certified mail, e - service, or fax . Signature American LegalNet, Inc. www.FormsWorkFlow.com