Attorney of Record: Docket No.: _________________ Filed: _________________ Fee: _________________ State of New Jersey Essex County Surrogate’s Court Hall of Records, Room 206 Newark, New Jersey 07102 Phone: 973-621-4900 Fax: 973-621-2654 JOSEPH P. BRENNAN, JR. SURROGATE In the matter of the Minor: ______________________________________________________, Deceased AKA: ________________________________________________ PATRICIA A. TRABUCCO DEPUTY SURROGATE } AFFIDAVIT FOR RECEIPT OF FUNDS PURSUANT TO N.J.S. 3B:12-6, ETC. STATE OF NEW JERSEY COUNTY OF ESSEX } SS. Affidavit of Spouse, Father or Mother or Person Having the Care and Custody of the Minor and with whom the Minor Resides, to Accepting Money or Personal Property of the Minor not Exceeding $5,000.00 Per Annum Pursuant To 3B:12-6 Etc. __________________________________, with Social Security #:______________, being duly sworn, says that this deponent resides at ______________________________ County of _____________, State of ______________, that they are the _______________________, person having care and custody and with whom the minor resides and said minor, ____________________________, is ___________________________ years old: That the personal estate of said minor does not exceed the sum of Five Thousand Dollars ($5,000.00) per annum and consists of: __________________________________, that this deponent is therefore entitled to receive the same without Letters of Guardianship. AND FURTHER same will be used for support and general use and benefit of the minor. I acknowledge receipt of the sum of $____________________________ and any balance thereof will be turned over to the minor upon their reaching the age of majority. Signature Sworn and subscribed before me on ______/______/______ I1 Page 1 of 1 American LegalNet, Inc. www.USCourtForms.com