COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. Attorney of Record: : : Plaintiff(s) -against- : Docket Index No. No.: _________________ Filed: _________________ Calendar No. Fee: _________________ JUDICIAL SUBPOENA : State of New Jersey : Salem County Surrogate’s Court : In the matter of the Minor: Defendant(s) : ...................................................... __________________________________________________, Deceased } AKA: ____________________________________________ AFFIDAVIT FOR RECEIPT OF FUNDS PURSUANT TO N.J.S. 3B:12-6, ETC. THE PEOPLE OF THE STATE OF NEW YORK STATE OF NEW JERSEY TO COUNTY OF SALEM } SS. Affidavit of Spouse, Father or Mother or Person Having the Care and Custody of the Minor and with whom the Minor GREETINGS: Resides, to Accepting Money or Personal Property of the Minor not Exceeding $5,000.00 Per Annum Pursuant To 3B:12WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 6 Etc. , the Honorable at the Court located at County of _______________________________________________________, being duly sworn, says that this deponent resides at in room , on the day of , 20 , at o'clock in the noon, and at any recessed _________________________________________________________________________________________________ or adjourned date, to testify and give evidence as a witness in this action on the part of the 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: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a That the personalof yourof said minor does not exceed the sum of Five Thousand Dollars ($5,000.00) per annum and result estate failure to comply. consists of: __________________________________, that this deponent is therefore entitled to receive the same without Witness, Honorable , one of the Justices of the Letters of Guardianship. Court in County, day of , 20 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(Attorney over signthe minortype name below) turned must to above and upon their reaching the age of majority. Signature Attorney(s) for Sworn and subscribed before me on: ______/______/20___ Office and P.O. Address I1.DOC Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: Page 1 of 1 American LegalNet, Inc. www.USCourtForms.com