JIS CODE: TES Approved, SCAO STATE OF MICHIGAN PROBATE COURT COUNTY OF FILE NO. TESTIMONY INTERESTED PERSONS Estate of 1. My name is: My address is: 2. I am related to the decedent (or know his/her family) as follows: 3. The date and time of death of the decedent is domicile (residence) was: Time Date and at that time, his/her Address NOTE: FOR THE FOLLOWING QUESTIONS TREAT ALL PERSONS WHO DIED WITHIN 120 HOURS AFTER THE DECEDENT AS IF THEY DID NOT SURVIVE THE DECEDENT. List persons who died within 120 hours after the Decedent in item 14 below. 4. The decedent did not leave a surviving spouse. left a surviving spouse named: 5. a. The decedent had the following children, both natural (born in or out of wedlock) and adopted: b. Of the children listed in 5.a, the following are no longer heirs due to their adoption by someone other than a step-parent: c. Of the children listed in 5.a, the following were not children of the surviving spouse: Answer question 6 only if question 5.a. was checked. 6. a. The following children listed in 5.a. died before the decedent: b. Children listed in 6.a. left their own children (either natural or adopted) or left grandchildren from one or more of their own predeceased children who survived the decedent. The names of these descendants and the name of the child in 6.a. to whom they are related is as follows: c. Of the persons listed in 6.b, the following are no longer heirs due to their adoption by someone other than a step-parent: SEE SECOND PAGE Do not write below this line - For court use only PC 565 (9/05) TESTIMONY, INTERESTED PERSONS MCL 700.2104, MCR 5.104(C), MCR 5.302(B), MCR 5.308(B)(2)(a) American LegalNet, Inc. www.FormsWorkflow.com If decedent left no surviving descendant, complete 7. 7. The decedent did not leave a surviving father and/or mother. left a surviving father and/or mother named: If decedent is not survived by spouse, descendants or parents, complete 8. (and 9. if applicable) 8. The decedent did not leave surviving brothers or sisters. left the the following brothers or sisters, either natural or adopted, whole blood or half blood, who were not adopted by others and who survived the decedent: 9. One or more of the brothers and sisters of the decedent died before him/her leaving descendants, either natural or adopted, who were not adopted by others and who survived the decedent. The names of these descendants, and the name(s) of their deceased ancestor are: If decedent was not survived by spouse, descendants, parent, brother, or sister or children of deceased brother or sister, complete 10. (and 11. if applicable) 10. The decedent did not leave surviving grandparents. left surviving grandparents (both maternal and paternal) named: 11. Both maternal grandparents and/or both paternal grandparents died before decedent. Their surviving descendants and their relationship to the grandparents are: Maternal grandparents: Paternal grandparents: 12. The following heirs listed above are under legal disability. Their name(s), legal disability, and name of their representative are: 13. The following deceased heirs survived the decedent by more than 120 hours. Their name(s) and the name(s) of those who represent his or her interests are: 14. The following persons identified above did not survive the decedent by 120 hours. Their name(s), relationship to decedent, and date and time of death are as follows: NAME RELATION DATE OF DEATH TIME OF DEATH The decedent left a will and some of the devisees named in the will and codicils are not heirs of the testator. A supplemental testimony form is completed and attached. Witness signature Subscribed and sworn to before me on My commission expires: , Date Date Signature: Judge/Deputy register/Notary public County, Michigan. Bar no. Notary public, State of Michigan, County of Attorney signature Name (type or print) Address Bar no. City, state, zip Telephone no. American LegalNet, Inc. www.FormsWorkflow.com