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. File No.______________________________ Deceased. ______________________________________________X 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) 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 $ _________________. (b) 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. b. Spouse (husband/wife). Divorced [Attach copy of Divorce Decree] Child or children or descendants of predeceased child or children, [M ust include marital, non-marital, and adopted]. Any issue of the decedent adopted by persons related to the decedent (DRL Section 117). Mother/Father. Sisters and brothers, either of whole or half blood, and issue of predeceased sisters and brothers. Grandm other/Grandfather. Aunts or uncles, and children of predeceased aunts and uncles (first cousins). First cousins once rem oved (children of first cousins). c. d. e. f. g. h. [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 deceden