ND PROBATE CODE FORM 15 Page 1 10/01/03 PERSONAL REPRESENTATIVE'S VERIFIED STATEMENT TO CLOSE THE ESTATE. (N.D.C.C. 30.1-21-03). Name, Address, and Telephone No. of Attorney Space below for use of District Court only Probate No. _____________ Attorney ___________________ for: IN THE DISTRICT COURT OF __________________________________ COUNTY, STATE OF NORTH DAKOTA In the Matter of the Estate of ________________________________________________________________, Deceased. PERSONAL REPRESENTATIVE'S VERIFIED STATEMENT TO CLOSE THE ESTATE STATE OF NORTH DAKOTA } } County of ____________________ } ss. _____________________________________________________________________, being duly sworn, states as follows: 1. I am the duly appointed, qualified and acting personal representative of the above estate. 2. I have published notice to creditors as provided in N.D.C.C. 30.1-19-01 and have filed proof of publication of such notice. The first publication occurred more than three months prior to the date of this statement. 3. I have fully administered the estate of the decedent by making payment, settlement or other disposition of all claims which were presented, expenses of administration and estate, inheritance and other death taxes except as follows: 4. I have distributed the assets of the estate to the persons entitled to the assets in the amount and manner to which they are entitled. (By agreement with the distributees the assets were distributed subject to outstanding liabilities of the estate.) 5. I have sent a copy of this statement to all distributees of the estate (and to all creditors or claimants of the estate whom I am aware whose claims are neither paid nor barred), and I have furnished a full account in writing of my administration to the distributees whose interests are affected thereby. 6. This statement is filed for the purpose of closing this estate and terminating the appointment of the undersigned pursuant to N.D.C.C. 30.1-21-03. ____________________________________________ Personal Representative Page 1 of NDPC FORM 15 American LegalNet, Inc. www.FormsWorkflow.com ND PROBATE CODE FORM 15 Page 2 } } County of ____________________ } 10/01/03 STATE OF NORTH DAKOTA ss. _______________________________________________________________________________, being first duly sworn, says that ___he is the personal representative of the above estate and that ___he has read the foregoing statements and knows the contents thereof, and verily believes the statements made therein to be true. ____________________________________________ Subscribed and sworn to before me this ___________________ day of _______________________, 20________. ____________________________________________ Notary Public __________________________ County, North Dakota (Seal) My Commission expires:________________________ Page 2 of NDPC FORM 15 American LegalNet, Inc. www.FormsWorkflow.com