THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Estate of Case Name: Case Number: (if known) 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. Funeral expenses and last sickness $ B. Other bills paid such as debts, taxes and estate expenses $ (List each specific bill and amount below.) 2. TOTAL BILLS PAID FROM ESTATE ASSETS AND INCOME EARNED $ 3. BALANCE IN HAND TO BE DISTRIBUTED TO LEGATEES OR HEIRS ONLY AFTER RECEIVING THE COURT'S APPROVAL $ , Voluntary Administrator of the estate, state the I, above is a true and accurate statement of my administration. I certify that a copy of this document has been provided to the parties who have filed an appearance for this case or who are otherwise interested parties. Date Voluntary Administrator Signature (must be signed in presence of notarial officer) State of , County of This instrument was acknowledged before me on by Date My Commission Expires Affix Seal, if any NHJB-2143-P (06/04/2008) (formerly AOC 203-003) Voluntary Administrator Signature of Notarial Officer / Title 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 NHJB-2143-P (06/04/2008) (formerly AOC 203-003) Judge Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com