en-USFile No. en-USSTATE OF NORTH CAROLINAen-US en-US Countyen-USIn The General Court Of Justiceen-USSuperior Court Divisionen-USBefore the Clerk en-USName Of Decedenten-USDate Of Deathen-USMarital Status Of Decedenten-USCounty Of Domicile At Date Of Deathen-USName And Address Of Applicanten-USName And Address Of Surviving Spouseen-USIN THE MATTER OF THE ESTATE OF en-USAPPLICATION FORen-USADMINISTRATION BY CLERKen-US en-US(Not To Exceed $5,000)en-USG.S. 28A-25-6 en-USWillen-USHas a year222s allowance (to a spouse and/or en-USeligible children of the decedent) been allotted? þ en-USYes þ No þ en-USMarried þ en-USSeparated þ en-USDivorced þ en-USSingle/Widow(er) þ Yes en-US Noen-US(Over) en-USRelationship Of Applicant To Decedenten-USTelephone No. Of Applicanten-USHeirsen-USRelationshipen-USAgeen-USMailing Address en-USAPPLICATION en-USThe undersigned applicant, pursuant to G.S. 28A-25-6, shows the Court that the person/entity named below is indebted to theen-USabove-named decedent. No administrator has been appointed and the amount owed the decedent does not exceed $5,000.00 anden-USwould not make the aggregate sum which has previously come into the Clerk222s hands exceed the sum of $5,000.00. The applicant en-USrequests the Clerk to authorize all funds held by the person or entity named below be paid to and administered by the Clerk. en-USAmounten-USAmounten-USASSETS en-USBank Accountsen-US (List checking, savings, etc., each account no. and balance)en-USUncashed Checksen-US$en-US$en-US$en-US$en-US$en-US$en-US$en-US$en-US$en-US$en-US$en-US$en-US$en-US$en-USTOTAL American LegalNet, Inc. www.FormsWorkFlow.com en-USFUNERAL EXPENSES en-USName And Address Of Funeral Homeen-USTelephone Number Of Funeral Homeen-USTax ID No. en-USBalance Dueen-USAmount Paiden-USTotal Funeral Expenses en-US$en-US$en-US$ en-USPersons Who Paid Any Part Of Funeral Expenses en-US(en-USName, Address, and Amount Paid - provide documentationen-US) en-US$en-US$en-US$en-US$en-US$ en-USNameen-USAddressen-USAmounten-USTOTAL NOTE TO APPLICANT: þ en-USen-USen-USen-USOTHER DEBTS en-USName, Address, And Tax ID Number Of Creditors en-USNameen-USAddressen-USTax ID No.en-USAmounten-US$en-US$en-US$en-US$en-US$ en-USTOTAL en-USCERTIFICATION en-USDateen-USSignatureen-USSignature Of Applicant en-USI hereby certify that the information shown above is true and correct to the best of my knowledge and belief.en-USSWORN/AFFIRMED AND SUBSCRIBED TO BEFORE MEen-USNOTE TO CLERK: en-US þ en-USDeputy CSC þ en-USAssistant CSC þ en-USClerk Of Superior Courten-USDate Commission Expiresen-US þ en-USNotaryen-USSEAL American LegalNet, Inc. www.FormsWorkFlow.com