SURROGATE'S COURT OF THE STATE OF NEW YORK COUNTY OF ___________________________________ ----------------------------------------------------------------------------X VOLUNTARY ADMINISTRATION, Estate of AFFIDAVIT IN RELATION TO SETTLEM ENT OF ESTATE UNDER ARTICLE 13, SCPA , Deceased. ---------------------------------------------------------------------------X STATE OF NEW YORK ) COUNTY OF____________________________) ss.: File No. (as of 9/96)* (INSTRUCTIONS: In com pleting this form , answer each question. This m ay be done in som e instances by crossing out words in parenthesis and in som e instances by inserting the required inform ation.) ,being duly sworn, depose and say I, (1) My dom icile is (Street Address) (City/Town/Village) (County My m ailing address is (State) (Zip) (Telephone Number) (If different from domicile) (2) My interest is: [ ] Distributee of decedent (Relationship) [ ] Other (Specify) (3) The nam e, dom icile, date, place of death, and citizenship of the decedent, to whose estate this proceeding relates, are as follows: Nam e of Decedent (a/k/a, if applicable): Dom icile of Decedent: (Street Address) Date of Death: (City/Town/Village) Place of Death: (City/Town/Village) Citizenship: (State) (County) (State) (4) Decedent died: [ [ ] Intestate (without a will) ] Testate (the original will is attached) (5) A search of the records of the Court shows that no application has been m ade in the estate of the decedent for voluntary adm inistration, letters of adm inistration or for probate of a will, and your affiant is inform ed and verily believes that no such application ever has been m ade to any other Surrogate's Court in this state. SE-2A *For use only where decedent died on or after August 29, 1996 SE-2A -1- American LegalNet, Inc. www.FormsWorkflow.com (6) The nam es and addresses of the decedent's distributees under New York law, including non-m arital children and descendants of predeceased non-m artial children, and their relationship to the decedent, are as follows: (If m ore space is needed, add a sheet of paper) Post Office Address, (Including Zip) _______________________ _______________________ Relationship Indicate if non-m arital) _______________________________ _______________________________ Nam e ____________________ ____________________ (7) (If decedent had a will) The nam e and address of all beneficiaries in the will of the decedent filed herewith are as follows: (If m ore space is needed, add a sheet of paper) Nam e _____________________ _____________________ _____________________ _____________________ Post Office Address, (Including Zip) ________________________ ________________________ ________________________ ________________________ Request _________________________________ _________________________________ _________________________________ _________________________________ 8) The value of the entire personal property, wherever located, of the decedent, exclusive of joint bank accounts, trust accounts, U.S. savings bonds POD (payable on death), and jointly owned personal property, or property exem pt under the EPTL §5-3.1, does not exceed $20,000.00. 9) The following, exclusive of joint bank accounts, trust accounts, U.S. savings bonds POD (payable on death), and jointly owned personal property, or property exem pt under EPTL §5-3.1, is a com plete list of all personal property owned by the decedent, either standing in his/her own nam e or owned by him /her beneficially and including item s of value in any safe deposit box. (If m ore space is needed, add a sheet of paper) Item s of Personal Property Separately Listed Value of Each Item TOTAL $ -2- American LegalNet, Inc. www.FormsWorkflow.com (10) All the liabilities of the decedent known to m e are as follows: (If m ore space is needed, add a sheet of paper) Nam e of Creditor Am ount Owed _ _______________________________________ ________________________________ (11) I undertake to act as voluntary adm inistrator/trix of the decedent's estate, and to adm inister it pursuant to Article 13 of the Surrogate's Court Procedure Act. I agree to reduce all of the decedent's assets to possession; to liquidate such assets to the extent necessary; to open an estate bank account in a bank of deposit or savings bank in this state, in which I shall deposit all m oney received; to sign all checks drawn on or withdrawals from such account in the nam e of the estate by m yself, as voluntary adm inistrator/trix; to pay the expenses of adm inistration, the decedent's reasonable funeral expenses and his/her debts in the order provided by law; and to distribute the balance to the person or persons and in the am ount or am ounts provided by law. As voluntary adm inistrator/trix, I shall file in this court an account of all receipts and of disbursem ents m ade. (12) I understand that this proceeding will not determ ine the estate tax liability, if any, in the event that the decedent had any interest in real property or any joint bank accounts, trust accounts, U.S. savings bonds POD (payable on death), or jointly owned or trust property. (13) If letters testam entary or of adm inistration are later granted, I acknowledge that m y powers as voluntary adm inistrator/trix shall cease, and I shall deliver to the court appointed fiduciary a com plete statem ent of m y account and all assets and funds of the estate in m y possession. Signature of Affiant Print Nam e Sworn to before m e on , 20 Notary Public My Com m ission Expires: (Affix Notary Stam p or Seal) Signature of Attorney: Print Nam e: Firm Nam e: Address of Attorney: Tel. No.: -3- American LegalNet, Inc. www.FormsWorkflow.com