ND PROBATE CODE FORM 16 10/01/03 SWORN STATEMENT OF PERSONAL REPRESENTATIVE CLOSING A SMALL ESTATE. (N.D.C.C. 30.1-23-04). 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. SWORN STATEMENT OF PERSONAL REPRESENTATIVE CLOSING A SMALL ESTATE STATE OF NORTH DAKOTA } } County of ____________________ } ss. ___________________________________________________________, being duly sworn, states the following under oath: 1. I am the duly appointed, qualified and acting personal representative of the above estate, appointed on __________ ______________________, __________, in the above Court. 2. To the best of my knowledge, the value of the entire estate, less liens and encumbrances, did not exceed the homestead allowance, exempt property, family allowance, costs and expenses of administration, reasonable funeral expenses, and the reasonable, necessary medical and hospital expenses of the last illness of the decedent. 3. I have fully administered the estate by disbursing and distributing it to the persons entitled thereto. 4. I have sent a copy of the closing statement to all distributees of the estate and to all creditors or other claimants of whom I am aware whose claims are neither paid nor barred and have furnished a full account in writing of personal representative's administration to the distributees whose interests are affected. 5. No order of the Court prohibits closing of the estate and the estate is not being administered by a supervised personal representative. This statement is filed for the purpose of closing the above estate and terminating my appointment as personal representative pursuant to N.D.C.C. 30.1-23-04. ____________________________________________ Subscribed and sworn to before me this __________________ day of ___________________________, _________. ____________________________________________ Notary Public __________________________ County, North Dakota (Seal) My commission expires:________________________ American LegalNet, Inc. www.FormsWorkflow.com