STATE OF NORTH CAROLINA County IN THE MATTER OF THE ESTATE OF File No. In The General Court Of Justice Superior Court Division Before The Clerk Name Of Decedent AFFIDAVIT OF COLLECTION, DISBURSEMENT AND DISTRIBUTION G.S. 28A-25-3(a)(2) I, the undersigned collector by affidavit, being first duly sworn, say that the following is a complete and accurate account of my receipts, disbursements, and distributions as collector by affidavit of the personal property of this estate. Accounting Period From Extending To PART I. SUMMARY 1. Total Personal Property Received As Shown in Part II ............................................................................ 2. Minus Spousal Allowance Approved By The Court Under G.S. 30-15..................................................... _ 3. Minus Disbursements (Debts or Expense) As Shown In Part III ............................................................. _ 4. Minus Distributions To Heirs As Shown In Part IV .................................................................................. _ 5. BALANCE AT THE END (This will always be zero) $ $ $ $ $ PART II. PERSONAL PROPERTY RECEIVED DATE RECEIVED RECEIVED FROM DESCRIPTION 0.00 VALUE (Over) TOTAL RECEIPTS $ American LegalNet, Inc. www.FormsWorkFlow.com AOC-E-204, Rev. 1/12 � 2012 Administrative Office of the Courts PART III. DISBURSEMENT (DEBTS OR EXPENSE) DATE PAID TO FOR $ AMOUNT TOTAL DISBURSEMENTS PART IV. BALANCE DISTRIBUTED TO HEIRS HEIRS $ AMOUNT $ TOTAL BALANCE Signature Of Affiant 1 Signature Of Affiant 2 $ SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Date Signature Date Signature Deputy CSC Notary Assistant CSC Date Commission Expires County Where Notarized Clerk Of Superior Court Deputy CSC Notary Assistant CSC Date Commission Expires County Where Notarized Clerk Of Superior Court SEAL SEAL AOC-E-204, Side Two, Rev. 1/12 � 2012 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com