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: ______________________________ SUPPLEMENTAL SURVIVING SPOUSE AFFIDAVIT OF ASSETS AND DECLARATION In Lieu of Administration Where Real and Personal Estate Does Not Exceed $20,000.00 (R.S. 3B:10-3) I, and say(s): 1. 2. I reside at I am surviving spouse of with a residence of New Jersey without leaving a Will. , of full age, being duly sworn, depose(s) . who died on , in the County of Essex and State of 3. 4. The decedent left no children or issue born to any person other than me. Except as show below, the parents of the decedent are not living: NAME Relationship 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: 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 same without Letters of Administration, in accordance with the Laws of New Jersey, N.J.S.A. 3B:10-3. Signature Subscribed and sworn to before me day of on this , 20 . Notary Public/Attorney at Law of New Jersey American LegalNet, Inc. www.FormsWorkFlow.com 2