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: APPLICATION FOR ADMINISTRATION BY CLERK Name Of Decedent (Not To Exceed $5,000) Date Of Death SSN Of Decedent (last 4 digits) Will? Yes No G.S. 28A-25-6 Marital Status Of Decedent Married Legally Separated Divorced Single County Of Domicile At Date Of Death Has a year's allowance been allotted? Name And Address Of Petitioner HEIRS Yes No Name And Address Of Surviving Spouse AGE SSN RELATIONSHIP MAILING ADDRESS PETITION The undersigned petitioner, pursuant to G.S. 28A-25-6, shows the Court that the person/entity named below is indebted to the above-named decedent. No administrator has been appointed and the amount owed the decedent does not exceed $5,000.00 and would not make the aggregate sum, which has come into the Clerk's hands, exceed the sum of $5,000.00. The petitioner requests the Clerk to authorize all funds held by the person or entity named below be paid to and administered by the Clerk. ASSETS Bank Accounts (List checking, savings, etc., ea. account no. and balance) AMOUNT $ $ $ $ Uncashed Checks $ $ $ $ $ $ $ $ $ TOTAL AOC-E-432, Rev. 4/08 © 2008 Administrative Office of the Courts (Over) $ FUNERAL EXPENSES Name and Address of Funeral Home Telephone Number of Funeral Home Tax ID No. Total Funeral Expenses Amount Paid Balance Due $ $ $ Persons Who Paid Any Part Of Funeral Expenses (Name, Address And Social Security Number) (Provide Documentation) Name Address SSN Amount $ $ $ $ TOTAL $ OTHER DEBTS Name, Address And Social Security Number Of Creditors Name Address Tax ID No. Amount $ $ $ $ TOTAL $ CERTIFICATION I hereby certify that the information shown above is true and correct to the best of my knowledge and belief. Signature Of Petitioner SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Date Name Of Petitioner (Type Or Print) Signature Address Deputy CSC Assistant CSC Telephone No. Clerk Of Superior Court Date Commission Expires Notary County Where Notarized SEAL NOTE TO CLERK: Use AOC-E-431 to authorize payment of funds to the clerk. NOTE TO APPLICANT: In lieu of submitting the full Tax ID number or social security number above, an heir, creditor, or person paying any part of the funeral expenses may complete and file form AOC-G-120. AOC-E-432, Side Two, Rev. 4/08 © 2008 Administrative Office of the Courts