File No. (TYPE OR PRINT IN BLACK INK) STATE OF NORTH CAROLINA In The General Court Of Justice Superior Court Division Before The Clerk County IN THE MATTER OF THE ESTATE OF: AFFIDAVIT FOR COLLECTION OF PERSONAL PROPERTY OF DECEDENT Name, Street Address, City, State And Zip Code Of Decedent (For Decedents Dying On Or Before Dec. 31, 2011) INTESTATE Social Security No. (Last Four Digits) County Of Domicile At Time Of Death Date Of Death Date Of Will TESTATE Place Of Death (If Different From County Of Domicile) G.S. 28A-25-1; 28A-25-1.1 Name, Street Address, PO Box, City, State And Zip Code Of Affiant 1 Name, Street Address, PO Box, City, State And Zip Code Of Affiant 2 Telephone No. Telephone No. Legal Residence (County, State) Legal Residence (County, State) Name, Street Address, PO Box, City, State And Zip Code Of Attorney Attorney Bar No. Telephone No. I, the undersigned affiant, being first duly sworn, say that: 1. I am an heir. an executor named in the will. a devisee named in the will. the public administrator a creditor of the decedent. I am not disqualified under G.S. 28A-4-2. 2. At least thirty (30) days have passed since the date of the decedent's death. 3. The decedent died intestate. testate. 4. (a) The decedent died on or before 9/30/09 and the value of all personal property owned by the decedent less liens and encumbrances thereon, does not exceed $10,000. (b) I am the surviving spouse and sole heir/devisee of the decedent, the decedent died on or before 9/30/09, and the value of all personal property, less liens and encumbrances thereon, does not exceed $20,000. (c) The decedent died on or after 10/1/09 and the value of all personal property owned by the decedent less liens and encumbrances thereon, does not exceed $20,000. (d) I am the surviving spouse and sole heir devisee of the decedent, the decedent died on or after 10/1/09, and the value of all personal property, less liens and encumbrances thereon, does not exceed $30,000. 5. (Check if decedent died testate.) Decedent's will dated as shown above has been probated in each county in which is located any real property owned by the decedent as of the date of death; and a certified copy of the decedent's will is attached to this Affidavit. 6. No application or petition for appointment of a personal representative is pending or has been granted in any jurisdiction. 7. After diligent inquiry, I have determined that the persons listed below are all the persons entitled to share in the decedent's estate. (If there is a court-appointed guardian for any such person(s), list the guardian's name and address on an attachment.) NAME AGE Original - File AOC-E-203A, Rev. 5/12 © 2012 Administrative Office of the Courts Copy - Fiduciary RELATIONSHIP MAILING ADDRESS Copy - Clerk Mails Copy To Each Person Listed In Item No. 7 (Over) American LegalNet, Inc. www.FormsWorkFlow.com PRELIMINARY INVENTORY (Give values as of date of decedent's death. Continue on separate attachment if necessary.) PART I. PROPERTY OF THE ESTATE Est. Market Value 1. Accounts in sole name of decedent (List bank, etc., each account no. and balance.) $ 2. Joint accounts without right of survivorship (List bank, etc., each account no., balance and joint owners.) % Owned By Dec. % Owned By Dec. % Owned By Dec. % Owned By Dec. 3. Stocks/bonds/securities in sole name of decedent or jointly owned without % Owned By Dec. right of survivorship............................................................................................. 4. Cash and undeposited checks on hand......................................................................................................... 5. Household furnishings.................................................................................................................................... 6. Farm products, livestock, equipment and tools.............................................................................................. 7. Vehicles (include or attach descriptions) 8. Interest in partnership or sole proprietor businesses...................................................................................... 9. Insurance, Retirement Plan, I.R.A., etc., payable to Estate........................................................................... 10. Notes, judgments, and other debts due decedent.......................................................................................... 11. Miscellaneous personal property.................................................................................................................... 12. Real estate willed to the Estate.................................................................... $ 13. Estimated annual income of Estate................................................................................................................ $ (Base bond on this amount, if applicable.) TOTAL PART I. PART II. PROPERTY WHICH CAN BE ADDED TO ESTATE IF NEEDED TO PAY CLAIMS 1. Joint accounts with right of survivorship (List bank, etc., each account no., balance and joint owners.) $ 2. Stocks/bonds/securities registered in beneficiary form and immediately transferred on death or jointly owned with right of survivorship ..................................................................................................................... 3. Other personal property recoverable G.S. 28A-15-10 ................................................................................... 4. Real estate owned by decedent and not listed elsewhere (attach description)................................................. PART III. OTHER PROPERTY TOTAL PART II. $ is is not entireties real estate owned by decedent and spouse .......................................... 1. There are are not Insurance, Retirement Plan, I.R.A., accounts, etc., payable to named 2. There beneficiaries.................................................................................................................................................... Signature Of Collector By Affidavit 1 Signature Of Collector By Affidavit 2 Name (Type Or Print) Name (Type Or Print) SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Date Signature Of Person Authorized To Administer Oaths Deputy CSC Notary SEAL Assistant CSC Date Commission Expires County Where Notarized Clerk Of Superior Court Signature Of Person Authorized To Administer Oaths Date Deputy CSC Notary SEAL Assistant CSC Clerk Of Superior Court Date Commission Expires County Where Notarized CERTIFICATION I certify that the foregoing is a true and accurate copy as taken from and compared with the original on record in this office. Date Signature Deputy CSC Assistant CSC Clerk Of Superior Court SEAL NOTE: This Affidavit for Collection of Personal Property of Decedent authorizes the named collector by affidavit to receive and administer ALL of the personal property belonging to the named decedent pursuant to G.S. Chapter 28A, Article 25. AOC-E-203A, Side Two, Rev. 5/12 © 2012 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com