Superior Court of the District of the Columbia PROBATE DIVISION WASHINGTON, D.C. 20001 Estate of Administration No. S.E. Deceased PETITION FOR ADMINISTRATION OF SMALL ESTATE . Name Age Address Name Age Address . Hereinafter, "petitioner" being a citizen of the United States or a lawfully admitted permanent resident thereof, of legal age, and not otherwise excluded from acting as personal representative pursuant to D.C. Code §20-303(b),. 1. , the decedent, a domiciliary of residing at . ,died at . Place on (with) (without) a will. 2. Petitioner is entitled to be appointed personal representative of the decedent's estate under D.C. Code §20-303 for the following reasons: . . 3. The court has jurisdiction in this matter because:  Decedent died domiciled in the District of Columbia  Other - please state basis for jurisdiction . . 4. There are no other proceedings regarding the administration of the estate except 5. Petitioner has made a diligent search to discover, all property and debts of the decedent. All assets subject to administration in the District of Columbia do not exceed $40,000 in value ($15,000 if decedent died between July 1, 1995 and April 26, 2001). 6. Petitioner has made a diligent search for wills and codicils of the decedent and, to the best knowledge of the petitioner, the will dated ________________________________________________________________________________________ and codicils dated ______________________________________________________________________________________ accompanying this petition (is) (are) the decedent's last will and petitioner knows of no later will or codicil. Said will and codicil(s), if any, came into petitioner’s hands in. the following manner: ___________________________________________ . . 7. All information required pursuant to D.C. Code §20-304(a) has been furnished except . Form PD(28)-1178A/June 95 5-1352-1wd-315 American LegalNet, Inc. www.FormsWorkflow.com -2The decedent is survived by (please check appropriate boxes): a. [ ] Spouse [ ] No spouse. Check appropriate box and go to b. b. [ ] Children. If so stop here; if not, go to c. c. [ ] Grandchildren. If so, stop here; if not, go to d. d. [ ] Parents. If so, stop here; if not go to e. e. [ ] Brothers and /or Sisters. If so, stop here; if not, go to f. f. [ ] Nieces and /or Nephews. If so, stop here; if not, go to g. g. [ ] Uncles and /or Aunts. If so, stop here; if not, go to h. h. [ ] First Cousins. If so, stop here; if not, go to i. i. [ ] Grandparents. If so, stop here; if not, go to j. j. [ ] Other heirs. If none, go to k. k. [ ] Notify Office of the Corporation Counsel, Special Litigation Section Washington, D.C. 20001 Indicate, when applicable, grandchildren and nieces and nephews by family groups, by showing the name of their deceased parent who was related to the decedent. LIST OF INTERESTED PERSONS must include names of heirs if decedent died intestate; heirs and legatees, including trustees and all named personal representatives if the decedent died testate. Refer to D.C. Code §19-301 through 312 and §20-101(d)(1). Add additional sheet if needed. Name of Heir/Legatee Address Relationship (Age, if under 18) If under age or otherwise legally disabled, also list guardians or custodian pursuant to D..C. Code §20-101(d)(A) WITNESS TO WILLS/CODICILS (Names) American LegalNet, Inc. www.FormsWorkflow.com Character, Location and Value of Property Titled in Decedent’s Name Real Property located in the District of Columbia and other jurisdictions Total $ Personal Property located in the District of Columbia and other jurisdictions Total $ Debts, Funeral Expenses, Inheritance, Taxes Debts secured: Total $ Debt, unsecured: Total $ Funeral Expenses: Total $ Paid byname Unpaid Total $ Inheritance taxes (if the decedent died prior to April 1, 1987) Only on personal property under control of personal representative Total $ American LegalNet, Inc. www.FormsWorkflow.com -3WHEREFORE, the petitioner prays for appointment as personal representative of the decedent’s estate and that the will dated and codicil(s) dated . be admitted to probate and record, and that the additional relief be granted . . DECLARATION OF PETITIONER I do solemnly declare and affirm under the penalty of law that the contents of the forgoing petition are true and correct to the best of my knowledge, information and belief. . Signature of Petitioner (Tel No.) Signature of Petitioner (Tel No.) Signature of Petitioner, (Tel No.) Signature of Petitioner (Tel. No.) . ACCEPTANCE AND CONSENT OF EACH PERSONAL REPRESENTATIVE I do hereby accept the duties of the office of personal representative of the estate of , deceased, and consent to personal jurisdiction in any action brought in the District of Columbia against me as personal representative or arising out of the duties of the office of personal representative pursuant to D.C. Code §20-501. . Signature of Petitioner Signature of Petitioner POWER OF ATTORNEY To be executed By Each Non-resident Personal Representative Pursuant to D.C. Code §20-303(b)(7), I do hereby irrevocably appoint the Register and Successors in office as the person upon whom all notices and process issued by a competent court in the District of Columbia may be served with the same effect as personal service in relation to all suits or matters pertaining to the estate in which the letters are to issue. . (Signature) . (Address) . (Signature) . (Address) American LegalNet, Inc. www.FormsWorkflow.com