NHJB-2499-P (10/01/2018) THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) MOTION TO PAY STATE TREASURER FOR PROPERTY IN EXCESS OF $5,000 RSA 561:10 1. Petitioner Name Capacity Petitioner Name Capacity 2. Attorney Name Telephone 3. I have settled the account of the administration for this estate. 4. I have the following sum of money: It belongs to: 5. That person222s place of residence is unknown, and I have done everything I can to find that person or his or her heirs; or, the person entitled to the sum has refused it. The petitioner asks to be authorized by the court to pay the sum to the State Treasurer. Such payment would be a discharge of the administrator222s duties as they relate to this property. Date Petitioner Signature State of , County of This instrument was acknowledged before me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title ORDER Motion to pay the sum of to the New Hampshire State Treasurer is granted. Send to the Abandoned Property Division, State Treasury, 25 Capitol St Room 121 Concord NH 03301 A receipt must be filed within days of this order. Motion is denied. Date Signature of Judge Name of Judge American LegalNet, Inc. www.FormsWorkFlow.com