AFFIDAVIT OF FINANCIAL RESPONSIBILITY - PERSONAL SURETY PC-410 REV. 10/09 STATE OF CONNECTICUT COURT OF PROBATE [Type or print in black ink. ] TO: COURT OF PROBATE, DISTRICT OF DISTRICT NO. DATE OF AFFIDAVIT ESTATE OF/IN THE MATTER OF FIDUCIARY [Name, address, and zip code] POSITION OF TRUST AMOUNT OF BOND PROPOSED PERSONAL SURETY [Name, address, and zip code] I, the proposed personal surety, submit this affidavit (1) as a true and accurate statement as to the assets shown and (2) as a true, accurate, and complete statement of all of my liabilities as of the date of this affidavit. DATE AND SIGN ON PAGE TWO. INSTRUCTIONS: All unsecured direct liabilities of the proposed personal surety must be shown. If any assets shown are owned jointly in survivorship, all joint owners must become sureties and sign the affidavit. If any assets shown are owned as tenants in common with others, then only the value of the share of the proposed surety shall be shown. Assets need be shown only to a total value of equity equal to the sum of the amount of the probate bond required, plus the total of the unsecured direct liabilities of the proposed surety. Assets may be shown in any of the categories listed. If an asset is listed which is security for a liability (e.g., mortgage, collateral loan, etc.), only the excess of the value of such asset over the liability it secures shall be shown. Give actual amounts. Do not approximate. Complete supporting schedules. If space is insufficient, attach supplemental schedule. ASSETS LIABILITIES Current Assets: 1. Bank Deposits (Sch. 1) .................... $ 2. Notes Receivable (Good) (amounts due within one year) (Sch. 2)... 3. Other Current Assets (Sch. 7).......................................... Marketable Securities: 4. Stocks and Bonds - Pledged (Sch. 4A)........................................ 5. Stocks and Bonds - Unpledged (Sch. 4B) ....................................... Real Estate: 6. Enter Equity from Sch. 3..................... Other Assets: 7. Life Insurance Cash Surrender Value................................ 8. Notes Receivable (amounts due beyond one year) (Sch. 2).......................................... 9. Other Stocks and Bonds (Sch. 4C)................................ 10. Miscellaneous Assets (Sch. 7)........................................ 11. TOTAL EQUITY VALUE OF ASSETS (Lines 1-10) ....................$ SCHEDULE 1: DEPOSITS (List Banks and Account Numbers) Amount 12. Suretyship on Other Probate Bonds...................................$ Unsecured Direct Liabilities: 13. Accounts Payable (Sch. 5)............ 14. Unpaid Interest, Taxes, etc......................................... 15. Notes Payable (Sch. 6)................. 16. Other Direct Liabilities (Sch. 7) ................................... 17. Total Amount of Suretyship on Other Probate Bonds and Unsecured Direct Liabilities (lines 12-16) .........$ 18. Amount of Assets Available for this Suretyship (line 11 minus line 17)................. 19. TOTAL OF LINES 17 AND 18 .................................$ SCHEDULE 2: NOTES RECEIVABLE (List Name and Address of Maker or Payor) Total AFFIDAVIT OF FINANCIAL RESPONSIBILITY - PERSONAL SURETY Continued PC-410 Amount Due on Note During next 12 beyond12 months months Totals American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF FINANCIAL RESPONSIBILITY - PERSONAL SURETY PC-410 REV. 10/09 Page 2 STATE OF CONNECTICUT COURT OF PROBATE [Type or Print] SCHEDULE 3: REAL ESTATE (List street, town, and state.) Indicate type and use of property. If mortaged, give name of mortgagee. Market Value Assessed Value SCHEDULE 4A: MARKETABLE STOCKS AND BONDS -PLEDGED (List Number of Shares, Name of Security, & Market Value.) Mortgage Balance Equity SCHEDULE 5: ACCOUNTS PAYABLE Amount Total Amount: If total amount exceeds $2,000, list creditors and amounts below. Total: SCHEDULE 4B: MARKETABLE STOCKS AND BONDS -UNPLEDGED (List Number of Shares, Name of Security, and Market Value.) SCHEDULE 6: NOTES PAYABLE (List Payees and Addresses) Amount Total: SCHEDULE 4C: OTHER STOCKS AND BONDS -UNPLEDGED (List Number of Shares, Name of Security, and Market Value.) SCHEDULE 7: EXPLANATION OF LINES 3,10, &16 Total: PLEASE ANSWER ALL OF THE QUESTIONS BELOW. IF THE ANSWER TO ANY QUESTION IS "YES," PLEASE EXPLAIN. 1. Are you presently or have you ever been surety on a probate bond in Connecticut? Yes No 2. Are you a co-maker on a note, or are you an endorser, guarantor, or otherwise contingently liable for the debts of another? Yes No 3. Do you have or anticipate unusual or above-normal demands on assets during the projected term of your suretyship, such as costs of college education, medical expenses, responsibility for parents, plans for retirement, or contemplated major capital expenditures? 4. Are you a party in a lawsuit? Yes Yes No No 5. Are there any judgments outstanding against you? Yes 6. Have you been declared bankrupt in the last fourteen years? No Yes No The representations contained herein are made under the penalties of false statement. Date: ................................................................................................. Proposed Personal Surety: AFFIDAVIT OF FINANCIAL RESPONSIBILITY - PERSONAL SURETY PC-410 American LegalNet, Inc. www.FormsWorkFlow.com