For Office Use Only Filing Fee Paid $ _____________________ ____________ ______________________ ____________ Certs: _________________ $ ___________ Bond, Fee: _____________ Receipt No: ________ No:______________ DO NOT LEAVE ANY ITEMS BLANK SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF ______________________________ ______________________________________________X LETTERS OF ADMINISTRATION d.b.n. ESTATE OF __________________________________ a/k/a PETITION FOR LETTERS OF ADMINISTRATION d.b.n. SCPA 1007 Letters of Adm inistration d.b.n. Letters of Adm inistration d.b.n. with Lim itations Lim ited Letters of Adm inistration d.b.n. ______________________________________ Deceased. ______________________________________________X File No.______________________________ TO THE SURROGATE’S COURT, COUNTY OF _____________: It is respectfully alleged: 1. (a) The nam e, citizenship, dom icile (or, in the case of a blank or trust com pany, its principal office) and interest in this proceeding of the petitioner(s) is/are as follows: Nam e: __________________________________________________________________________________________ ________________________________________________________________________________________________ Dom icile or Principal Office: (Street and Number) (City, Village or Town) _______________________________________________________________________________________ (County) (State) (Zip Code) (Telephone Number) Mailing Address: __________________________________________________________________________________________ (If different from domicile) Citizenship (Check one): U.S.A. Other (specify) Nam e: _________________________________________________________________________________________________ (Street and Number) (City, Village or Town) _______________________________________________________________________________________________________ (County) (State) (Zip Code) (Telephone Number) Dom icile or Principal Office: _________________________________________________________________________ Mailing Address: ___________________________________________________________________________ (If different from domicile) Citizenship (Check one): U.S.A. Other (specify) Interest (s) of Petitioner (s): [Check one] Distributee of decedent (state relationship) ________________________________________________ Other [Specify] ______________________________________________________________________ No 1. (b) Is the proposed Adm inistrator d.b.n. an attorney? Yes [NOTE: If yes, subm it statem ent pursuant to 22 NYCRR 207.16(e); see also 207.52] 2. Letters of Adm inistration of the above-nam ed decedent were issued by this court on ________________, to _______________________, who on __________________ died resigned was rem oved. ADM/DBN-1 (7/98) -1­ American LegalNet, Inc. www.FormsWorkFlow.com [Note: For paragraphs 3a through c: Do not include any assets that are jointly held, held in trust for another, or have a named beneficiary.] 3. (a) (b) The estim ated gross value of unadm inistered personal property passing by intestacy is less than $ _________________. The estim ated gross value of the decedent’s unadm inistered real property, in this state, which is im proved unim proved, passing intestacy is less then $ _________________. A brief description of each parcel is as follows: __________________________________________________________________________________ __________________________________________________________________________________ (c) The estim ated gross rent for a period of eighteen (18) m onths is the sum of $ _________________. (d) In addition to the value of the personal property stated in paragraph (3) (a), the following right of action existed on behalf of the decedent and survived his/her death, or is granted to the adm inistrator of the decedent by special provision of law, and it is im practical to give a bond sufficient to cover the probable am ount to be recovered therein: (W rite “NONE” or state briefly the cause of action and the person against w ho it exists, including nam es and carrier]. (e) If decedent is survived by a spouse and a parent, or parents but no issue, and there is a claim for wrongful and furnish nam es (s) and address (es) of parent (s) in paragraph 5. death, check here See EPTL 5-4.4. 4. The decedent left surviving the following who would inherit his/her estate pursuant to EPTL 4-1.1 and 4-1.2: a. Spouse (husband/wife). b. Child or children or descendants of predeceased child or children, [M ust include marital, non-marital, and adopted]. c. Any issue of the decedent adopted by persons related to the decedent (DRL Section 117). d. Mother/Father. e. Sisters and brothers, either of whole or half blood, and issue of predeceased sisters and brothers. f. Grandm other/Grandfather. g. Aunts or uncles, and children of predeceased aunts and uncles (first cousins). h. First cousins once rem oved (children of first cousins). Divorced [Attach copy of Divorce Decree] [Inform ation is required only as to those classes of relatives who would take the property of decedent pursuant to EPTL 4-1.1. State “numbers” of survivors in each class. Insert “NO” in all prior classes. Insert “X” in all subsequent classes]. -2­ American LegalNet, Inc. www.FormsWorkFlow.com 5. The decedent left surviving the following distributees, or other necessary parties, whose nam es, degrees of relationship, dom iciles, post office addresses and citizenship are as follows: [Note: Show clearly how each person is related to decedent. If relationship is through an ancestor who is deceased, give name, date of death, and relationship of the ancestor to the decedent. Use rider sheet if space in Paragraph (5) is not sufficient. See Uniform Rules 207.16 (b). If any person listed in paragraph (5) is a nonmarital person, or descended from a nonmarital person, attach a copy of the order of filiation or Schedule A. If any person listed in paragraph (5) was adopted by any persons related by blood or marriage to decedent or descended from such persons, attach Schedule B.] 5a. The following are of full age and under no disability: [If nonm arital or adopted-out person, so indicate by attaching Schedule A and/or B. If any of the distributees have died subsequent to the death of the decedent, give the nam e and title of the legal representative appointed for such person (s), his or her address and the court that issued such letters. If any distributee who has died, subsequent to the death of the decedent, has no legal representative, then enter the nam e, relationship, dom icile address and citizenship of that deceased person (s) distributee (s).] Nam e Relationship ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ 5b. Dom icile and Mailing address ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ Citizenship ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ The following are infants and/or persons under disability: [Attach applicable Schedule A, B, C and/or D] Nam e ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ Relationship Dom icile and Mailing address ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ______________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ____________________ ____________________ -3­ Citizenship ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ ___________________ American LegalNet, Inc. www.FormsWorkFlow.com 6. There are no persons interested in this proceeding other than those herein m entioned. 7. There are no outstanding debts or funeral expenses, except: [W rite “NONE” or state sam e] __________________________________________________________________________________________ W HEREFORE, your petitioner (s) respectfully pray (s) that: [Check and com plete all relief requested] a. Process issue to all necessary parties to show cause why letters should not be issued as requested; b. An order be granted dispensing with service of process upon those persons nam ed in paragraph 5 who have a right to letters prior or equal to that of the person nom inated, and who are non-dom iciliaries or whose nam es or whereabouts are unknown and cannot be ascertained; c. A decree award Letters of Adm inistration d.b.n. to ____________________________________ ____________________________________________________________________________ or to such other person or persons having a prior right as m ay be entitled thereto, and; d. That the authority of the representative under the foregoing Letters be lim ited with respect to the prosecution of a cause of action on behalf of the estate, as follows: the adm inistrator (s) m ay not enforce a judgm ent or receive any funds without further order of the Surrogate. e. That the authority of the representative under the foregoing Letters be lim ited as follows: ____________________________________________________________________________ ____________________________________________________________________________ f. [State any other relief requested]. _________________________________________________ ____________________________________________________________________________ Dated:_______________________________________ 1. __________________________________________ (Signature of Petitioner) 2. _______________________________________ (Signature of Petitioner) ___________________________________________ (Print Nam e) ________________________________________ (Print Nam e) 3.__________________________________________ (Nam e of Corporate Petitioner) ___________________________________________ (Signature of Petitioner) ___________________________________________ (Print Nam e and title of Officer) -4­ American LegalNet, Inc. www.FormsWorkFlow.com SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF ___________________________ _________________________________________X LETTERS OF ADMINISTRATION d.b.n. ESTATE OF _______________________________ a/k/a SCHEDULE A NONM ARITAL PERSONS (PERSONS BORN OUT OF W EDLOCK) ___________________________________ File No. ________________________________ Deceased. X [NOTE: Nonm arital children (or their issue) who would be distributees if they (or their ancestors) were born in wedlock will not be regarded as distributees unless satisfactory proof is subm itted establishing paternity]. See EPTL 4-1.2, which sets forth m ethods of establishing paternity. Nam e of alleged distributee: ________________________________________________________________ Date of birth: ____________________ Relationship to decedent: ____________________________________ Nam e of father: ____________________________________________________________________________________ Nam e of m other: _____________________________________________________________________________ Does the birth certificate contain the father’s nam e? Yes No If yes, attach a copy of birth certificate. Has an order of filiation establishing paternity been entered? Yes No If yes, attach a copy of order. Did the nonm arital person live with his or her father? Yes No If yes, give dates and place of residence: __________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ -5­ American LegalNet, Inc. www.FormsWorkFlow.com SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF ______________________________ X LETTERS OF ADMINISTRATION d.b.n. ESTATE OF ____________________________________ SCHEDULE B ISSUE OF THE DECEDENT W HO WERE THE SUBJECT OF AN ADOPTION File No: ______________________________ a/k/a _____________________________________ Deceased. ______________________________________________X Nam e of child: ______________________________________________________________________________ Relationship to decedent prior to adoption: _______________________________________________________ Date of adoption: ___________________________________________________________________________ W as this a ste-parent adoption? (i.e., was the child adopted by the spouse of the decedent’s form er spouse?) No Yes If yes, nam e of adoptive father or m other: _________________________________________ If not a step-parent adoption, indicate below the biological relationship of the adoptive parent to the child: grandparents (s) brother or sister aunt or uncle first cousin nephew or niece Nam e of the adoptive parent __________________________________________________________________________ -6­ American LegalNet, Inc. www.FormsWorkFlow.com SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF _______________________________ X LETTERS OF ADMINISTRATION d.b.n. ESTATE OF ___________________________________ SCHEDULE C INFANTS File No. ______________________________ a/k/a _______________________________________ Deceased. ______________________________________________ X Nam e: _______________________________________________ Date of birth: _______________________ Relationship to the decedent: _________________________________________________________________ W ith whom does the infant reside? ____________________________________________________________ Nam e of m other: ________________________________________ Is she alive? ________________________ Nam e of father: Is he alive? Does the infant have a court-appointed guardian? No Yes If yes, nam e and address of guardian: Nam e: Date of birth: Relationship to the decedent: W ith whom does the infant reside? Nam e of m other: Is she alive? Nam e of father: Is he alive? Does the infant have a court-appointed guardian? Yes No If yes, nam e and address of guardian: -7­ American LegalNet, Inc. www.FormsWorkFlow.com SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF _______________________________ X LETTERS OF ADMINISTRATION d.b.n. ESTATE OF ____________________________________ a/k/a SCHEDULE D PERSONS UNDER DISABILITY OTHER THAN INFANTS ________________________________________ File No. Deceased. X [Use additional sheets if needed] 1. Nam e: Relationship: Residence: W ith whom does this person reside? If this person is in prison, nam e of prison: Does this person have a court-appointed fiduciary? Yes No If yes, give nam e, title and address: If no, describe nature of disability: If no, give nam e and address of relative or friend interested in his or her welfare: 2. W hereabouts unknown/Unknowns [persons whose addresses or nam es are unknown to petitioner; if known, give nam e and relationship to decedent]: _____________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ -8­ American LegalNet, Inc. www.FormsWorkFlow.com COM BINED VERIFICATION, OATH & DESIGNATION [For use when petitioner is to be appointed adm inistrator d.b.n.] STATE OF_________________) COUNTY OF_______________) ss: The undersigned, the petitioner nam ed in the foregoing petition, being duly sworn, says: 1. VERIFICATION: I have read the foregoing petition subscribed by m e and know the contents thereof, and the sam e is true of m y own knowledge, except as to the m atters therein stated to be alleged upon inform ation and belief, and as to those m atters I believe it to be true. 2. OATH OF ADMINISTRATOR d.b.n.: I am over eighteen (18) years of age and a citizen of the United States; I will well, faithfully and honestly discharge the duties of the adm inistrator d.b.n.. I am not ineligible to receive letters. 3. DESIGNATIO N O F CLERK FOR SERVICE OF PROCESS: I do hereby designate the Clerk of the Surrogate’s Court of County, and his or her successor in office, as a person on whom service of any process issuing from such Surrogate’s Court m ay be m ade, in like m anner and with like effect as if it were served personally upon m e, whenever I cannot be found within the State of New York after due diligence used. My dom icile is (Street Address) (City/Town/Village) (State) (Zip Code) (Signature of Petitioner) (Print Nam e) On , , before m e personally cam e to m e known to be the person described in and who executed the foregoing instrum ent. Such person duly swore to such instrum ent before m e and duly acknowledged that he/she executed the sam e. Notary Public Com m ission Expires: (Affix Notary Stam p or Seal) Signature of Attorney: Print Nam e: Firm Nam e: Tel. No.: Address of Attorney: -9­ American LegalNet, Inc. www.FormsWorkFlow.com COM BINED CORPORATE VERIFICATION, CONSENT AND DESIGNATION [For use when a petitioner to be appointed is a bank or trust com pany] STATE OF_________________) COUNTY OF_______________) ss: The undersigned, a of (Title) (Nam e of Bank or Trust Com pany) a corporation duly qualified to act in a fiduciary capacity without further security, being duly sworn, says: 1. VERIFICATION: I have read the foregoing petitioner subscribed by m e and know the contents thereof, and the sam e is true of m y own knowledge, except as to the m atters therein stated to be alleged upon inform ation and belief, and as to those m atters I believe it to be true. 2. CONSENT: I consent to accept the appointm ent as Adm inistrator d.b.n. of the decedent described in the foregoing petition and consent to act as such fiduciary. 3. DESIGNATION OF CLERK FOR SERVICE OF PROCESS: I do hereby designate the Clerk of the Surrogate’s Court of County, and his or her successor in office, as a person on whom service of any process issuing from such Surrogate’s Court m ay be m ade, in like m anner and with like effect as if it were served personally upon m e, whenever I cannot be found within the State of New York after due diligence used. (Nam e of Corporate Petitioner) ________________________________________ (Signature of Officer) _______________________________________ (Print Nam e and Title of Officer) On the __________________________ , __________, before m e personally cam e _______________________ to m e known, who duly sworn to the foregoing instrum ent and who did say that he/she resides at ___________________ ______________________ and that he/she is a ________________________________________________________ of _______________________________the corporation/national banking association described in and which executed such instrum ent, and the he/she signed his/her nam e thereto by order of the Board of Directors of the corporation. _____________________________________ Notary Public Com m ission Expires: (Affix Notary Stam p or Seal) Signature of Attorney: Print Nam e: Firm Nam e: Tel. No.: Address of Attorney: -10­ American LegalNet, Inc. www.FormsWorkFlow.com