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: 973-621-2654 DEVERO D. MCDOUGAL DEPUTY SURROGATE In the matter of the Estate of: _____________________________________________, Deceased AKA: _______________________________________ } SUBSTITUTIONARY ADMINISTRATOR C.T.A. QUALIFICATION ___________________________, the Substitutionary Administrator/rix(s) C.T.A., in the annexed writing named, being duly sworn on oath, says, that the foregoing writing contains the true Last Will and Testament of ______________________________, the Testator/rix therein named, deceased, as far as they know and verily believe; that they will, as such Substitutionary Administrator/rix C.T.A., well and truly perform the same, first by paying the debts of said deceased and then the legacies therein specified as far as the goods, chattels and credits of said deceased will thereunto extend and the law charges them; that they will make and exhibit unto the Surrogate's Office of the County of Essex a true and perfect inventory of all and singular the said goods, chattels and credits as far as the same have or shall come to their possession or knowledge, or to the possession of any other person or persons for their use with their knowledge; and that they will well and truly account when thereunto lawfully required; and that said testator/rix died on ____________________. Signature STATE OF NEW JERSEY COUNTY OF ESSEX } SS. Be it remembered, that on this, ______/______/______, before me, undersigned authority, personally appeared _______________________________________ who I am satisfied are the persons in the within instrument named, and I having first made known to them the contents thereof, did acknowledged that they signed, sealed and delivered the same as their voluntary act and deed, for the uses and purposes therein espressed. __________________________________________________ Notary Public of the State of New Jersey My Commission Expires: ____________________________ Affix Seal 3_SUB_ADM_CTA_QUALIFICATION American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 1