STATE OF CONNECTICUT STATEMENT IN LIEU OF ACCOUNT PC-243 REV. 7/05 RECORDED: COURT OF PROBATE [Type or print in black ink.] DISTRICT NO. TO: COURT OF PROBATE, DISTRICT OF ESTATE OF in said district, deceased. FIDUCIARY(IES) [Name(s), address(es), zip code(s), and telephone number(s)] THE FIDUCIARY(IES) HEREBY REPRESENTS UNDER PENALTIES OF FALSE STATEMENT THAT: At least one fiduciary is a residuary distributee in his/her own right, and no part of the residue is distributable to a testamentary or living trust. The total amount inventoried is $ All debts, funeral expenses, taxes, and expenses of administration have been paid. All specific bequests have been or will be paid in full. The amount reported on the Return of Claims and List of Notified Creditors, PC-237, on file is $ paid as indicated. and has been All distributees have received a copy of this statement. An itemized list of all funeral expenses, taxes, and expenses of administration is as follows: Funeral Expenses: $ Taxes: 1) Town of 2) State of Connecticut a) Succession and/or Estate Taxes b) Income Tax 3) Internal Revenue Service a) Estate Tax b) Income Tax Administration Expenses: Probate court costs Fiduciary bond premium Recording and advertising costs Fiduciary's fees and disbursements Attorneys' fees and disbursements Other [Attach second sheet, if necessary.] Bequests already made to: Name [Include specific and residuary beneficiaries.] Proposed distribution to: $ $ $ $ $ $ $ $ $ $ $ $ $ $ Name $ Show any reserve $ remaining WHEREFORE, SAID FIDUCIARY(IES) REQUESTS discharge from further liability for accounting and return to this court, pursuant to C.G.S. §45a-176. The fiduciary also requests the issuance of a Certificate of Devise, Descent, or Distribution of the real property described in the Inventory to the extent not sold or otherwise conveyed. [If part of the real property has been sold or otherwise conveyed, explain fully and attach revised legal description thereto.] The representations contained herein are made under the penalties of false statement. ......................................................................................... Fiduciary: .................................................................................................. Fiduciary: Date: Date: STATEMENT IN LIEU OF ACCOUNT PC-243 American LegalNet, Inc. www.USCourtForms.com