JDF 967 SC R 6 / 1 9 VERIFIED APPLICATION FOR CERTIFICATE FROM REGISTRAR Page 1 of 1 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 VERIFIED APPLICATION FOR CERTIFICATE FROM REGISTRAR PURSUANT TO 247 15 - 12 - 1007, C.R.S. I, , as the p ersonal r epresentative s urety state: 1. The appointment of (name) as p ersonal r epresentative of this estate has terminated. 2. The p e rsonal r e presentative has fully administered this estate according to law. 3. No action concerning this estate is pending in any court. I request that the r egistrar issue a c ertificate stating that this estate appears to have been fully administered and evidencing discharge of any lien on any property given to secure the obligation of the p ersonal r epresentative in lieu of bond or any surety. 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. 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) Attorney Signature, (if any) Date American LegalNet, Inc. www.FormsWorkFlow.com