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 DEVERO D. MCDOUGAL DEPUTY SURROGATE In the matter of the Estate of: ____________________________, Deceased AKA: ___________ ___ NEXT OF KIN AFFIDAVIT OF ASSETS AND DECLARATION In Lieu of Administration Where Real and Personal Estate Does Not Exceed $20,000.00 (R.S. 3B:10-4) I, and say(s): 1. 2. , of full age, being duly sworn, depose(s) 3. 4. I reside at . I am related to who died on , in the County of Essex and State of with a residence of New Jersey without leaving a Will. The decedent was my _____________________________. All of the decedent's next of kin are as follows: NAME Relationship (and age if a minor) ADDRESS/RESIDENCE 1 American LegalNet, Inc. www.FormsWorkFlow.com 5. The assets in the sole name of the decedent or held "as tenants in common" with decedent, known to me at this time do not exceed the sum of $20,000.00, and are as follows (with documentary proofs of each asset attached): 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. $ $ Therefore, I am entitled to take custody of and duly administer said assets without Letters of Administration, in accordance with the Laws of New Jersey, N.J.S.A. 3B:10-4 and will report the findings of any additional assets. ___________________________________ 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