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: CHILD SUPPORT VERIFICATION KNOW ALL MEN BY THESE PRESENTS, that I hereby certify that I have been given a copy of N.J.S.A. 2A:17-56.23b advising me as to my obligation to determine if child support arrearages exist against any beneficiary entitled to receive more than $2,000.00 and to satisfy same prior to disbursement of funds payable to said beneficiary identified as owing said child support. ___________________________ Signature Print Name: 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 expressed. ____________________________________________ Notary Public of the State of _______________________________ My Commission Expires: ______________________ Affix Seal American LegalNet, Inc. www.FormsWorkFlow.com