Approved, SCAO JIS CODE: SST STATE OF MICHIGAN PROBATE COURT COUNTY OF FILE NO. SWORN STATEMENT TO CLOSE UNSUPERVISED ADMINISTRATION SUPPLEMENTAL Estate of 1. I am the personal representative of this estate. Upon filing this sworn statement with the court, this estate will be closed without a hearing. More than five months have passed since the date of my original appointment as personal representative. 2. I have published notice to creditors as required by law and the time for presentment of claims has expired. 3. I have fully administered this estate by paying, settling, or disposing of the claims that were presented, the estate and administration expenses, and all other taxes. I have distributed the assets of the estate to the persons entitled to the assets.* 4. The interested persons, addresses, and their representatives are identical to those appearing on the initial application/petition, except as follows: 5. a. No Michigan estate or inheritance tax is due. b. Michigan estate tax or inheritance tax has been paid in full (evidence of full payment from Michigan Department of Treasury is attached). 6. I sent a copy of this sworn statement to all distributees and to all claimants whose claims are neither paid nor barred and to all demandants. I furnished a full account in writing to the distributees whose interests are affected by the administration. 7. I reopened the estate and have completed the administration. Personal representative signature Address Personal representative name (type or print) City, state, zip Sworn to before me on Telephone no. County, Michigan. Date My commission expires: Signature: Date Notary public, State of Michigan, County of Attorney signature Attorney name (type or print) Address Bar no. City, state, zip Telephone no. NOTICE TO INTERESTED PERSON(S): You may object to this sworn statement by filing written objections with the probate court mentioned above along with a $20.00 filing fee. If an objection is not filed within 28 days after this sworn statement is filed with the court, the probate register may issue a certificate stating that it appears that you have fully administered this estate. The certificate does not preclude any action against you or the surety on a bond you may have obtained. If an action or proceeding involving you is not pending in this court one year after this sworn statement is filed, your appointment ends. *Note: Specify any exceptions. If any claims remain undischarged, state whether the estate was distributed subject to possible liability with the agreement of the distributees, or state in detail other arrangements that were made to accommodate outstanding liabilities. Do not write below this line - For court use only PC 591 (9/07) SWORN STATEMENT TO CLOSE UNSUPERVISED ADMINISTRATION MCL 700.3954, MCL 700.3958, MCR 5.311(A), (C) American LegalNet, Inc. www.FormsWorkflow.com