NANCY D. FITZGIBBONS, SURROGATE OF SUSSEX COUNTY 3 High Street, Suite 1, Newton, New Jersey 07860 FAX (973) 579-0909 Office (973) 579-0920 ESTATE OF:_____________________________________DOD:_________________ THE DEBTS IN THE NAME OF THE DECEDENT ALONE ARE AS FOLLOWS: FUNERAL cost: $____________ Balance due:$____________ $_______________ Circle One: *Prepaid *Insurance paid *Estate paid *Other paid (Name:_____________________) _________________________________________ $___________________ _________________________________________ $___________________ _________________________________________ $___________________ _________________________________________ $___________________ _________________________________________ $___________________ _________________________________________ $___________________ _________________________________________ $___________________ TOTAL: $___________________ American LegalNet, Inc. www.FormsWorkflow.com