SURROGATE'S COURT OF THE STATE OF NEW YORK COUNTY OF _______________________________ -----------------------------------------------------------------x In the Matter of Deceased. -----------------------------------------------------------------x TO BE COMPLETED BY FIDUCIARY or ATTORNEY FOR FIDUCIARY Total Estate Assets (see below)* __________ Filing fee SCPA 2402(7) $__________ Filing fee initially paid $__________ Balance (Refund) Due $__________ INVENTORY OF ASSETS (Rule §207.20) File No:_____________________________ The undersigned, a fiduciary or attorney for the fiduciary of the above Decedent's estate, certifies that the following constitutes the gross estate for tax purposes and identifies whether non-estate assets exist. Complete below according to the following value categories: Category A - under $10,000; Category B - $10,000 to under $20,000; Category C - $20,000 to under $50,000; Category D - $50,000 to under $100,000; Category E - $100,000 to under $250,000; Category F - $250,000 to under $500,000; Category G - $500,000 or over. Date of Death:____________ Date of Letters:____________ Type of Letters:______________________________ CATEGORY ___________ ___________ ___________ ___________ ___________ ___________ ___________ Yes ­ see attached firearms inventory None ___________ Name of Fiduciary(ies) and, if changed, fiduciary(ies) address: _____________________________________________ ASSETS INDIVIDUALLY OWNED BY DECEDENT OR PAYABLE TO ESTATE 1. Real Estate 2. Stocks and Bonds 3. Insurance Payable to Estate 4. IRAs, 401 Ks Payable to Estate 5. Mortgages or Notes Held by Decedent 6. Cash 7. Miscellaneous 8. Firearms (Check appropriate box) *TOTAL ESTATE ASSETS NON-ESTATE ASSETS - CHECK YES OR NO TO EACH OF THE FOLLOWING: 9. Living Trust Yes No If yes, set forth the Name of the Trustee(s) ____________________________________________ 10. Gifts in Excess of Federal Annual Exclusion Made Yes No Within 3 Years of Decedent's Death 11. Jointly Held Property (Real or Personal) Yes No 12. Insurance Payable to Beneficiary Yes No 13. IRAs, 401K's Payable to Beneficiary Yes No 14. Annuities Yes No 15. Powers of Appointment Yes No 16. Cause(s) of Action Pending Yes No If yes, identify Court and Index Number ____________________________________________ Certified to be true on the ______ day of _____________________, 20____. ________________________________________ Signature ____________________________________________________ Attorney's Name ________________________________________ Print Name I-1 3/2016 ____________________________________________________ Attorney's Address ____________________________________________________ Attorney's Telephone No. American LegalNet, Inc. www.FormsWorkFlow.com