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): Case Number: Phone Number: FAX Number: Division E-mail: Atty. Reg.#: Courtroom VERIFIED STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE The undersigned personal representative of this estate states: 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. (Section 15-12-1203, C.R.S.) 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 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 and 1204, 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 NOTE: This form is to be used only if a probate estate has previously been opened and a personal representative has been appointed. CPC 28 R7/00 VERIFIED STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE 1 2001 © American LegalNet, Inc. CERTIFICATE OF SERVICE I certify that on (date) ____________________________, a copy of this Verified Statement of Personal Representative Closing Small Estate 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 28 R7/00 VERIFIED STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE 2 2001 © American LegalNet, Inc.