THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Estate of STATEMENT OF VOLUNTARY ADMINISTRATION ESTATE ASSETS AND INCOME (List personal estate assets as reported on Voluntary Administration Affidavit and income earned on estate assets.) A. B. C. 1. TOTAL ESTATE ASSETS AND INCOME $ $ $ $ BILLS PAID FROM ESTATE ASSETS AND INCOME (List only expenses paid from estate assets reported on Voluntary Administration Affidavit and income earned on estate assets.) A. B. Funeral expenses and last sickness Other bills paid such as debts, taxes and estate expenses (List each specific bill and amount below.) $ $ 2. 3. TOTAL BILLS PAID FROM ESTATE ASSETS AND INCOME EARNED BALANCE IN HAND TO BE DISTRIBUTED TO LEGATEES OR HEIRS ONLY AFTER RECEIVING THE COURT'S APPROVAL $ $ I, , Voluntary Administrator of the estate, state the above is a true and accurate statement of my administration. I certify that on this date I provided this document(s) to the parties who have filed an appearance for Hand-delivery OR US Mail OR this case or who are otherwise interested parties by: Email (E-mail only by prior agreement of the parties based on Circuit Court Administrative Order). Date Voluntary Administrator Signature (must be signed in presence of notarial officer) State of This instrument was acknowledged before me on , County of by Date Voluntary Administrator Signature of Notarial Officer / Title My Commission Expires Affix Seal, if any NHJB-2143-P (03/25/2013) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Estate of Case Number: STATEMENT OF VOLUNTARY ADMINISTRATION ORDER This statement is approved. This statement is disapproved. Date Judge NHJB-2143-P (03/25/2013) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com