SUPERIOR COURT OF THE DISTRICT OF COLUMBIA PROBATE DIVISION _________ SEB _________ Estate of ________________________________ Deceased VERIFICATION OF ASSETS (To be filed when required by Preliminary Order) The Special Administrator of the above-listed estate hereby verifies that the assets of the estate are as follows and that documentation verifying the amounts listed is attached: Asset __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ __________________________________ Value $________ $________ $________ $________ $________ $________ $________ $________ Total value of assets: $____________ I do solemnly declare and affirm under penalty of law that the contents of the foregoing document are true and correct to the best of my knowledge, information, and belief. _______________________________________ Signature of special administrator __________________________________________ Typed name of special administrator February 2013 � 207.10.v3 American LegalNet, Inc. www.FormsWorkFlow.com __________________________________________ Address (actual address/not Post Office Box) __________________________________________ __________________________________________ __________________________________________ Telephone number __________________________________________ Email address __________________________________________ Unified Bar number (if filer is an attorney) CERTIFICATE OF SERVICE I certify that on the ____ day of ______________, 20___, a copy of this filing was either eServed in accordance with the provisions of Administrative Order 13-15 or served by first class mail, postage prepaid, on the following persons (list names and complete mailing addresses): _________________________________ Signature February 2013 � 207.10.v3 American LegalNet, Inc. www.FormsWorkFlow.com