Revised 09/2018 1 of 3 473.090.1 (1) RSMo APPLICATION FOR REFUSALS Fees of $ 103.50 due Add all parties: applicant and decedent Need c opy of death certificate with decedent222s SS# & address Need SS# and birthdate of Applicant Need documentation in support of asset(s) trying to collect (ie car title, bank statement) Spousal222s Refusal should contain the following: Need date of death of decedent Need domicile address of decedent Need a statement that decedent was survived by spouse and number of unmarried minor children Need a statement that left an estate, the value of which, less liens and encumbrances, is not greater in amount than is allowed by law as exempt property and maintenance of spouse and unmarrie d minor children for one year from death of decedent Need description and value of the property attempting to collect Need names, addresses and custodian of unmarried minor children Need a statement if children are or are not children of the surviv ing spouse Need to be signed and dated by applicant under oath and affirmation or notarized American LegalNet, Inc. www.FormsWorkFlow.com Revised 09/2018 2 of 3 473.090.1 (1) RSMo TWENTY SECOND JUDICIAL CIRCUIT Probate Division Case Number: In the Estate of , Deceased. (Date File Stamp) Application of Surviving Spouse for Refusal of Letters The applicant, surviving spouse of the decedent, states that decedent died on residing at , survived by applicant and unmarried minor child(ren), leaving an estate in this state, the value of which, less liens and encumbrances, is not greater in amount than is allowed by the law as exempt property and maintenance of applicant and unmarried minor child(ren) for one year after the death of decedent. The estate consists solely of the property described and of value as follows: Description of Property Value See Appendix A. Total $ Unmarried minor child(ren) of the decedent who is(are) not the child(ren) of the applicant is(are) as follows: Name of Child Date of Birth Name/Address of Custodian Wherefore, applicant prays the court order that no letters be granted on said estate unless on the application of creditors or other interested parties, the existence of other or further property is shown. The applicant swears that the matters set forth above are true and correct to the best knowledge and belief of the applicant, subject to the penalties of making a false affidavit or declaration. Date: Signature of Attorney for Applicant Signature of Applicant (Name/Bar Number/Address/Telephone/Fax/EMail) (Name/Address/Telephone) American LegalNet, Inc. www.FormsWorkFlow.com Revised 09/2018 3 of 3 473.090.1 (1) RSMo Appendix A Decedent: Case Number: Description of Property Value Real Property Personal Property TOTAL: American LegalNet, Inc. www.FormsWorkFlow.com