Docket No.: State of New Jersey 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 Natalynn Dunson-Harrison DEPUTY SURROGATE In the matter of the Estate of: ____________________________, Deceased AKA: ______________________________ ADMINISTRATION SURVIVING SPOUSE OR DOMESTIC PARTNER AFFIDAVIT OF ASSETS AND DECLARATION , of full age, being duly sworn, depose(s) I, and say(s): 1. I reside at . 2. I am surviving spouse/domestic partner of who died on ___________________, with a residence of______________________________in the County of Essex and State of New Jersey without leaving a Will. The decedent left no children or issue born to any person other than me. The parents of the decedent are not living, except as shown below: NAME Relationship 3. 4. ADDRESS/RESIDENCE American LegalNet, Inc. www.FormsWorkFlow.com 1 5. The assets in the sole name of the decedent or held "as tenants in common" with decedent, known to me at this time, are as follows: TOTAL ESTIMATED AMOUNT/VALUE $ $ ITEMS Cash on hand: Balances in bank accounts of decedent (list accounts) Corporate Stocks, bonds and notes, etc: $ Life insurance taken out by decedent without A named beneficiary or payable to the Estate: $ Automobiles (include year, made, model, and VIN #): $ Household effects, jewelry, other chattel, etc.: $ All other personal property belonging to the Estate: (Refund checks, security deposits, etc.) $ Real Estate, located at (list separately by type and address): (If market value is unknown, may use tax assessed value) $ REMARKS: TOTAL VALUATION OFF ALL PROPERTY: $ 6. If any additional assets are discovered, the Surrogate's Court will be informed. Signature Subscribed and sworn to before me on this day of , 20 . Notary Public/Attorney at Law of New Jersey 2 American LegalNet, Inc. www.FormsWorkFlow.com