en-USEstate of First, middle, and last name þ 1. þ My name is en-US . My address is en-US þ en-US .en-US2. I am related to the decedent (or know his/her family) as follows: en-US3. The date and time of the death of the decedent is Date þ Time en-US and at that time theen-US decedent222s domicile (residence) was Address en-US .en-USNOTE: IN THE FOLLOWING QUESTIONS, TREAT ALL PERSONS WHO DIED WITHIN 120 HOURS AFTER THE DECEDENT AS IFen-US THEY DID NOT SURVIVE THE DECEDENT. List persons who died within 120 hours after the decedent in item 14 below. 4. þ The decedent þ þ did not leave a surviving spouse. þ þ left a surviving spouse named en-US . 5. þ þ a. þ The decedent had the following children, both natural (born in or out of wedlock) and adopted: þ þ þ b. þ Of the children listed in 5.a, the following are no longer heirs due to their adoption by someone other than a stepparent: þ þ þ c. þ Of the children listed in 5.a, the following were not children of the surviving spouse: þ en-USAnswer question 6 only if question 5.a. was checked. 6. þ þ a. þ The following children listed in 5.a. died before the decedent: þ þ þ b. þ Children listed in 6.a. left their own children (either natural or adopted) or left grandchildren from one or more of their þ own predeceased children who survived the decedent. The names of these descendants and the name of the child in þ 6.a. to whom they are related are as follows: þ þ en-USþ c. þ Of the persons listed in 6.b, the following are no longer heirs due to their adoption by someone other than a stepparent: þ en-USIf decedent left no surviving descendant, complete 7. 7. þ The decedent þ þ did not leave a surviving parent. þ þ left a surviving parent named þ en-US . American LegalNet, Inc. www.FormsWorkFlow.com en-USFile No.en-US en-USIf decedent is not survived by spouse, descendants, or parents, complete 8 (and 9, if applicable). 8. þ The decedent þ þ did not leave surviving brothers or sisters. þ þ left the following brothers or sisters, either natural þ or adopted, whole blood or half blood, who were not adopted by others and who survived the decedent: þ þ þ 9. þ One or more of the brothers and sisters of the decedent died before him/her leaving descendants, either natural or en-US adopted, who were not adopted by others and who survived the decedent. The names of these descendants, and theen-US name(s) of their deceased ancestor are þ þ en-US . en-USIf decedent was not survived by spouse, descendants, parent, brother, or sister or children of deceased brother or sister, completeen-US en-US10 (and 11, if applicable). 10. þ The decedent þ þ did not leave surviving grandparents. þ þ left surviving grandparents (both maternal and paternal) named þ en-US . þ 11. þ Both maternal grandparents and/or both paternal grandparents died before decedent. Their surviving descendants þ and their relationships to the grandparents are þ Maternal grandparents: en-US . þ þ Paternal grandparents: en-US . þ 12. þ The following heirs listed above are under legal disability and are currently living. Their name(s), legal disability, and þ þ name(s) of their representative(s) are en-US þ en-US . þ 13. þ The following deceased heirs survived the decedent by more than 120 hours. Their name(s) and the name(s) of those þ who represent decedent222s interests are þ en-US þ en-US . þ 14. þ The following persons identified above did not survive the decedent by 120 hours. Their names, relationships to þ decedent, and the date and time of their deaths are: en-USNAMEen-USRELATIONen-USDATE OF DEATHen-USTIME OF DEATH 15. The decedent left a will. þ þ All devisees are heirs. þ þ Some of the devisees named in the will or codicil are not heirs þ of the testator. en-US(A supplemental testimony form is completed and attached.) þ Signature en-USSubscribed and sworn to before me on Date en-US , en-US County, Michigan.en-USMy commission expires: Date en-US Signature: Judge/Deputy register/Notary public þ Bar no. en-USNotary public, State of Michigan, County of Attorney signature þ Address Name (type or print) Bar no. þ City, state, zip Telephone no. en-US American LegalNet, Inc. www.FormsWorkFlow.com