Decedent222s Estate Administration Account (Short Form) PC - 242 REV. 7/19 CONNECTICUT PROBATE COURTS Decedent222s Estate Administration Account (Short Form) PC - 242 Page 1 of 3 RECEIVED: Instructions: 1) A fiduciary may use this form to account for a decedent222s estate unless the court has ordered the fiduciary to account for income and principal separately, or Probate Court Rules of Procedure, section 38.1 requires a separate principal and income accounting. 2)Report all assets at fiduciary acquisition value unless otherwise indicated. See Probate Court Rules ofProcedure, section 36.14. 3)Attach supporting schedules as required under Probate Court Rules of Procedure, section 38.2(d).4)The fiduciary must send a copy of this account to each party and attorney and certify to the court that acopy has been sent.5)For further information, see C.G.S. section 45a-175 et seq. and Probate Court Rules of Procedure, rules36 through 38.6)Type or print in ink. Use an additional sheet, or PC-180, if more space is needed. Probate Court Name District Number Estate of Hereinafter referred to as the decedent Fiduciary (Name, address and telephone number of each fiduciary) Position of Trust The fiduciary represents that: 1)The following is a true and complete account of all assets of the decedent222s estate and the fiduciary222s receipts,payments and distributions. 2)All funeral expenses, taxes, administration expenses and all claims against the estate allowed by the fiduciary areshown below and have been fully paid, and there are no claims now outstanding against the estate. 3)All supporting records for this account have been retained as required by Probate Court Rules of Procedure,section 36.13, and the records are available for review upon request. ASSETS AND INCOME RECEIVED BY FIDUCIARY Total amount reported on the inventory as on file Total amount of additional assets received [Attach schedule.] Cash advanced to the estate by Does the person who advanced funds expect reimbursement? Yes No Income received [Attach schedule.] Gains realized on the sale of assets [Attach schedule; if real property has been sold, attach settlement statement from closing in addition to schedule.] Adjustments increasing fiduciary acquisition value [Attach schedule.] Total assets and income received by fiduciary: American LegalNet, Inc. www.FormsWorkFlow.com Decedent222s Estate Administration Account (Short Form) PC - 242 REV. 7 /19 CONNECTICUT PROBATE COURTS Estate of Decedent222s Estate Administration Account (Short Form) PC - 242 Page 2 of 3 PAYMENTS AND DISTRIBUTIONS BY FIDUCIARY Funeral expenses Administration expenses [Attach schedule.] Total amount of allowed claims as reported on PC-237, Return of Claims and List of Notified Creditors that were paid by the fiduciary Losses realized on the sale of assets [Attach schedule; if real property has been sold, attach settlement statement from closing in addition to schedule.] Adjustments decreasing fiduciary acquisition value [Attach schedule.] Distributions already made to heirs or beneficiaries [Attach schedule of distributions at fiduciary acquisition value and fair market value.] Assets on hand [Attach schedule of assets on hand at fiduciary acquisition value and fair market value and schedules showing proposed distribution and reserve.] Total payments and distributions by fiduciary: CASH RECONCILIATION Cash reported on inventory or last account Income Additional cash receipts Proceeds from sale of assets Other cash transactions Total cash received by fiduciary: Funeral expenses Administration expenses Claims paid Distributions Other cash transactions Cash on hand Total cash payments and distributions by fiduciary: WHEREFORE each fiduciary requests that the court approve this account, approve and order distribution in accordance with the schedule of proposed distribution attached hereto, and release each fiduciary from liability with respect to all items shown in this account. The representations made in this account are made under penalty of false statement. Signature of Fiduciary Signature of Fiduciary Type or Print Name Type or Print Name Date Date American LegalNet, Inc. www.FormsWorkFlow.com Decedent222s Estate Administration Account (Short Form) PC - 242 REV. 7 /19 CONNECTICUT PROBATE COURTS Estate of Decedent222s Estate Administration Account (Short Form) PC - 242 Page 3 of 3 CERTIFICATION I certify that a copy of this account was sent to the following persons as provided in the Probate Court Rules of Procedure, section 30.12: Name and Address Signature of Fiduciary or Attorney Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com