District Court Denver Probate Court _________________________________________ County, Colorado Court Address: IN THE MATTER OF THE ESTATE OF: Deceased: Attorney or Party Without Attorney (Name and Address): COURT USE ONLY Case Number: Phone Number: FAX Number: Division E-mail: Atty. Reg.#: Courtroom VERIFIED STATEMENT OF PERSONAL REPRESENTATIVE CLOSING ADMINISTRATION The undersigned personal representative of this estate states: 1. Six months have passed since the original appointment of a general personal representative for this estate or at least one year has passed since the decedent’s death. The date of the original appointment was ____________________________. 2. Except as may be disclosed on an attached explanation, the undersigned or a preceding personal representative has fully administered this estate 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 decedent’s estate’s federal and state income taxes. The assets of the estate have been distributed to the 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 explanation as remaining undischarged, an explanation of arrangements for their disposition is also listed. 3. The undersigned has sent a copy of this statement 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 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. (Section 15-12-1003, C.R.S.) DATE:______________________________________________ As the personal representative and being sworn, I verify that the facts set forth in this statement are true to the best of my knowledge, information and belief. ___________________________________________________ ___________________________________________ Type or Print name of Attorney for Personal Representative Signature of Personal Representative (Type or Print name, address & tele.# below) ___________________________________________ ___________________________________________ State of ___________________________________________ ___________________________________________ _________________County of _________________________ ___________________________________________ Subscribed and sworn to before me by the personal representative on ________________________________________________ ___________________________________________ My commission expires _______________________________ Notary Public/(Deputy) Clerk of Court CPC 27 R7/00 VERIFIED STATEMENT OF PERSONAL REPRESENTATIVE CLOSING ADMINISTRATION 1 2001 © American LegalNet, Inc. CERTIFICATE OF SERVICE I certify that on (date) ____________________________, a copy of this Verified Statement of Personal Representative Closing Administration was served on each of the following at the indicated address by: hand delivery first class U.S. mail, postage pre-paid certified U.S. mail, postage pre-paid registered U.S. mail, postage pre-paid Name and Address ___________________________________________ Signature of Person Certifying Service NOTE: This certificate of service cannot be used in cases where personal service is required or used. Use CPC7-P (Personal Service Affidavit) or CPC8-A (Waiver of Service) for each person required to be served personally. CPC 27 R7/00 VERIFIED STATEMENT OF PERSONAL REPRESENTATIVE CLOSING ADMINISTRATION 2 2001 © American LegalNet, Inc.