CIRCUIT COURT OF CLAY COUNTY, MISSOURI PROBATE DIVISION No. Matter of , Deceased. STATEMENT AS TO DEATH, DELIVERY OF PURPORTED WILL AND, APPLICATION FOR PROBATE OR REJECTION Applicant states that , age _______, who resided at , died on the ______ day of _______________________, 20_____ and that said decedent left an instrument in writing, as *his - *her purported Will dated the ________ day of _______________________, 20_____, which is hereby delivered to the Probate Division of the Circuit Court in accordance with Section 473.043 RSMo. Applicant requests that an order be entered either admitting said instrument to probate as the Last Will and Testament of said decedent or rejecting same from probate. THE STATEMENTS AND REPRESENTATIONS IN THIS DOCUMENT ARE MADE UNDER OATH AND ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THEY ARE MADE SUBJECT TO THE PENALTIES OF MAKING A FALSE AFFIDAVIT OR DECLARATION. Date______________ Applicant’s Signature____________________________________________ Address_____________________________________________ _____________________________________________ Phone_____________________________________________ Attorney Register No. _____________________________________________ *strike if inapplicable Form 502-D Revised 3/17/2003 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com