Essex County Surrogate's Court THEODORE N. STEPHENS II SURROGATE Hall of Records, Room 206 Newark, New Jersey 07102 Phone: 973-621-4900 Fax: 973-621-2647 DEVERO D. MCDOUGAL DEPUTY SURROGATE State of New Jersey Docket No.: In the matter of the Estate of: , Deceased AKA: } SSN: APPLICATION ADMINISTRATION AD PROSEQUENDUM Applicant (s) , at Says: 1. Decedent late of , , departed this life on , intestate. 2. The spouse and next of kin of the decedent, with their respective addresses, and the manner and degree in which they severally stand related to the deceased are as follows: Name Relationship Residence Age of all Minors 3. There are no other next of kin and all the foregoing are of full age except as indicated above. 4. Either due notice of this application has been given to, or, all competent adult a, whose right to Administration Ad Prosequendum is prior or equal to that of the Applicant(s), have renounced their right thereto and requested that the same be granted to the Applicant(s). 5. The death of the said was caused by the wrongful act, neglect or default of or some other person or persons. Wherefore, the Applicant(s) request(s) judgment that of the said the statute in such cases provided. Dated: / / Signature be appointed Administrator/rix Ad Prosequendum to prosecute any action, proceeding or claim for their death brought or made under ADMINISTRATION -AD.PROS. Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com  Docket No.: STATE OF NEW JERSEY COUNTY OF ESSEX } SS. , being duly sworn, says; I am/we are the Applicant(s) in the foregoing application named. The allegations thereof are true to the best of my/our knowledge and belief. Sworn and subscribed before me on: / /20 Signature Notary Public of the State of New Jersey My Commission Expires: Affix Seal STATE OF NEW JERSEY COUNTY OF ESSEX SS. QUALIFICATION , being duly sworn, say(s); 1. 2. died on or about without a Will so far as I know and verily believe. I will well and truly perform the duties of Administrator/rix Ad Prosequendum of the said deceased. Sworn and subscribed before me on: / /20 Signature Notary Public of the State of New Jersey Attorney of Record: ADMINISTRATION -AD.PROS. Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com