MISSOURI CIRCUIT COURT, TWENTY-SECOND JUDICIAL CIRCUIT PROBATE DIVISION, CITY OF ST. LOUIS STATEMENT OF SURVIVING SPOUSE I, , surviving spouse of , decedent: with unmarried minor children, hereby state: (b) Property appointed to the spouse $ (c) Proceeds of life insurance $ (d) Proceeds of annuity contracts $ (f) Disability Compensation $ (g) Death benefits of retirement plan proceeds $ (h) Value of any community property $ (i) Jointly owned property $ (j) Cash $ (k) Real estate $ TOTAL $ 2. I estimate that I need an allowance of $ to cover these (b) Food $ (c) Clothing $ (d) Maintenance of home $ (f) Medical Care $ (g) Insurance premiums (health, home, auto) $ (h) Other: $ $ TOTAL $ THE FOREGOING IS MADE UNDER OATH OR AFFIRMATION AND ITS REPRESENTATIONS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF, SUBJECT TO THE PENALTIES OF MAKING A FALSE AFFIDAVIT OR DECLARATION. DATED: AFFIANT (ATTORNEYS: NOTE SECTIONS 474.260, 474.250 AND 474.163 RSMo) American LegalNet, Inc. www.FormsWorkFlow.com