Revised 01/2018, CN 12011 (Certification of Assets) page 1 of 2 NOTICE: This is a not a public document. The information entered on this form will be kept confidential. You therefore must enter all requested information, including any requested personal identifying information, such as your Social Security number, driver222s license number, or active bank or credit card accounts. Filing Attorney Information or Pro Se Litigant: Name NJ Attorney ID Number Law Firm/Agency Name Address Telephone Number Superior Court of New Jersey Chancery Divisio n - Probate Part In the Matter of , County , Docket Number Civil Action Certification of Assets Name of Alleged Incapacitated Person (AIP) an Alleged Incapacitated Person I, , of full age, hereby certify as follows: This certification is made by me in support of an application for a declaration of incapacity for . (Check one) Th e alleged incapacitated person, , possesses no property, or possesses only Social Security benefits , a State-funded Personal Needs Allowance, and/or funds held in trust for his/her b enefit. (Note: If you select this option, check 223None224 Schedules A-F below. If the alleged incapacitated person possesses Social Security benefits, describe them in Schedule G; if not, check 223None.224) OR The following schedules contain a complete and accurate statement and valuation of all real and personal property and income of , based upon my diligent inquiry. Schedule A: Real Prope rty None Unknown All interests in real property including real property held in common or jointly with other(s) and, if held jointly, describe the interest. # Description: Address (include county and state) Municipal Tax Assessed Value Market Value 1. $ $ 2. $ $ Total Schedule A $ Schedule B: Stocks, Bonds, Mutual Funds, Sec urities and Investment Accounts None Unknown Include all interests in stocks, bonds, mutual funds, securities and investment a ccounts including interests held in common or jointly with other(s) or in trust, and, if held jointly, describe the interest. # Description (include name of financial institution, account type, number of shares or last four digits of account and date val ue fixed) Face Value Market Value 1. $ $ 2. $ $ Total Schedule B $ American LegalNet, Inc. www.FormsWorkFlow.com Revised 01/2018, CN 12011 (Certification of Assets) page 2 of 2 Schedule C: Money on Hand None Unknown Checking and savings accounts and certificates of deposit in banks and notes or other indebtedness due the alleged incapacitated person . # Description (include name of financial institution, account type, last four digits of account and date value fixed) Value 1. $ 2. $ Total Schedule C $ Schedule D: Pensions, retirement accounts None Unknown IRA222s, 401(k), annuities, profit sharing plans, etc. Include last four digits of account . # Description ( include name of financial institution, account type, last four digits of account and date value fixed ) Value 1. $ 2. $ Total Schedule D $ Schedule E: Miscellaneous Personal Property None Unknown Tangible personal property, motor vehicles, recreation vehicles, employment bonus or award, interest in a partnership or un incorporated business, articles or collections have either artistic or intrinsic value, etc . # Description Value 1. $ 2. $ Total Schedule E $ Sched ule F: Liabilities/Encumbrances None Unknown If any asset li sted in this certification has a secured associated debt, such as a mortgage or a car loan, indicate below. List all other debts . # Description Encumbrance Amount 1. $ 2. $ Total Schedule F $ Schedu le G: Sources of Monthly Income None Unknown # Description Value 1. $ 2. $ Total Schedule G $ I hereby certify and say that the foregoing statements made by me are true to the best of my knowledge, and that I will supplement this form as may be necessary should additional information become available. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment . Date Signature Print Name American LegalNet, Inc. www.FormsWorkFlow.com