Docket No.: ______________ 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 State of New Jersey In the matter of the Estate of: ________________________________________________, Deceased AKA: __________________________________________ } ADMINISTRATOR C.T.A. QUALIFICATION STATE OF NEW JERSEY COUNTY OF ESSEX } SS. ______________________________, the Administrator/rix(s) CTA, 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 Administrator/rix C.T.A. will 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 Surrogates 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 knowledge; and that _______________ will well and truly account when thereunto lawfully required; and that said testator/rix died on _______________________. Signature Subscribed and Sworn to before me on ______/______/______ __________________________________________________ Notary Public of the State of New Jersey My Commission Expires: ____________________________ Affix Seal 6 ADMIN CTA QUAL American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 1