‰District Court ‰Denver Probate Court ___________________________________ County, Colorado Court Address: In the Matter of the Estate of: COURT USE ONLY Deceased Attorney or Party Without Attorney (Name and Address): Case Number: Phone Number: FAX Number: Division E-mail: Atty. Reg. #: Courtroom STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE PURSUANT TO §15-12-1204, C.R.S (Personal Representative of this estate) state the following: I, 1. The value of the entire estate of the Decedent, less liens and encumbrances, did not exceed the value of personal property held by or in the possession of the Decedent as fiduciary or trustee, exempt property, family allowance, costs and expenses of administration, reasonable funeral expenses, and reasonable and necessary medical and hospital expenses of the last illness of the Decedent. 2. The undersigned has fully administered this estate by disbursing and distributing it to the persons entitled. 3. The undersigned has sent a copy of this Statement to all distributees of this estate and to all creditors or other claimants to whom the undersigned is aware whose claims are neither paid nor barred and has furnished a full account in writing of the undersigned’s administration to the distributees whose interests are affected. 4. No Court order prohibits the informal closing of this estate. Administration of this estate is not supervised. This Statement is filed for the purpose of closing this estate. The appointment of the Personal Representative will terminate one year after this Statement is filed with the Court if no proceedings involving the undersigned are then pending. VERIFICATION I (Personal Representative) verify that the facts set forth in this document are true as far as I know or am informed. I understand that penalties for perjury follow deliberate falsification of the facts stated herein. (§15-10310, C.R.S.) ____________________________________________ Signature of Personal Representative Date ______________________________________ Signature of Attorney Date NOTE: This form is to be used only if a probate estate has been opened and a Personal Representative has been appointed. JDF 966 1/09 STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATE OF SERVICE I certify that on ________________________ (date) a copy of this Statement was served on each of the following: Full Name Relationship to Decedent *Insert one of the following: Address Manner of Service* Hand Delivery, First-Class Mail, Certified Mail, E-Served or Faxed. ___________________________________________ Signature JDF 966 1/09 STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com