JDF 966 SC R 6 /1 9 STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE 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 SMALL ESTATE PURSUANT TO 24715 - 12 - 1 204 , C.R.S I, ( p ersonal r epresentative ) , state the following : 1. The value of the entire estate of the d ecedent, less liens and encumbrances, did not exceed the value of personal property held by or in the possession of the d ecedent 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 d ecedent. 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 s tatement to all distributees of this estate and to all creditors or othe r claimants to whom the undersigned is aware whose claims are neither paid nor barred and has furnished a 4. No c ourt order prohibits the informal c losing 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 epresentative 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 t he original content of this form . 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 oth er location, and state OR country) (city or other location, and state OR country) American LegalNet, Inc. www.FormsWorkFlow.com JDF 966 SC R 6 /1 9 STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE Page 2 of 2 (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 Note : This form is to be used only if a probate estate has been opened and a P ersona l Re presentative has been appointed. American LegalNet, Inc. www.FormsWorkFlow.com