PROBATE COURT OF CUYAHOGA COUNTY, OHIO ANTHONY J. RUSSO, Presiding Judge LAURA J. GALLAGHER, Judge ESTATE OF _______________________________________________________________, DECEASED CASE NUMBER:_____________________________ APPLICATION TO RELIEVE ESTATE FROM ADMINISTRATION (R.C. 2113.03) Applicant states that decedent died on _______________________________________________________________________ Decedent’s domicile was___________________________________________________________________________________ Street Address _______________________________________________________________________________________________________ City or Village, or Township if unincorporated area County _______________________________________________________________________________________________________ Post Office State Zip Code (Check one of the following) G G Decedent’s will has been admitted to probate in this Court. To applicant’s knowledge, decedent did not leave a Will. (Check one of the following) G G G G G G The assets are $15,000 or less and decedent died on or after January 1, 1976. The assets are $25,000 or less and decedent died on or after October 20, 1987. The assets are $35,000 or less and decedent died on or after November 9, 1994. The assets are $50,000 or less; the surviving spouse is entitled to all of the assets and the decedent died on or after April 16, 1993. The assets are $85,000 or less; the surviving spouse is entitled to all of the assets and the decedent died on or after September 14, 1993. The assets are $100,000 or less; the surviving spouse is entitled to all of the assets and the decedent died on or after March 18, 1999. Applicant asks that the estate be relieved from administration because the assets do not exceed the statutory limits. A statement of the assets and liabilities of the estate is listed on the attached Form 5.1. The decedent’s surviving spouse, next of kin, legatees, and devisees known to applicant, are listed on the attached Form 1.0. (Check, if applicable) G Decedent was fifty-five years of age or older at the time of death and was a recipient of medical assistance under chapter 5111 of the Revised Code. Form 7.0 Notice to Administrator of Estate Recovery Program has been or will be fi led. _______________________________________________ ____________________________________________ Attorney For Applicant Applicant _______________________________________________ ____________________________________________ Typed or Printed Name Typed or Printed Name _______________________________________________ ____________________________________________ Address Address _______________________________________________ ____________________________________________ _______________________________________________ ____________________________________________ Phone Number (include area code) Phone Number (include area code) Attorney Registration No. __________________________ FORM 5.0 - APPLICATION TO RELIEVE ESTATE FROM ADMINISTRATION 3/99 American LegalNet, Inc. www.FormsWorkflow.com WAIVER OF NOTICE The undersigned surviving spouse, heirs at law, legatees, devisees and other persons entitled to notice of the filing of the application to relieve decedent’s estate from administration, waive such notice. ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ________________________________________ _________________________________________ ENTRY SETTING HEARING AND ORDERING NOTICE The Court sets ____________________________, at _________ o’clock __. M, as the date and time for hearing the application to relieve decedent’s estate from administration. [Check one of the following] G All notice is dispensed with as unnecessary. G Notice by publication to interested parties is dispensed with as unnecessary. Written notice shall be given, as provided by law and the Rules of Civil Procedure, to those persons entitled to notice, who have not waived notice. G Written notice is dispensed with as unnecessary. Notice by publication shall be given to interested parties as provided by law and the Rules of Civil Procedure. G Written notice shall be given to those persons entitled to notice, who have not waived notice, and notice by publication shall be given to interested parties, as provided by law and the Rules of Civil Procedure. ________________________________________ Date _________________________________________ Probate Judge American LegalNet, Inc. www.FormsWorkflow.com PROBATE COURT OF CUYAHOGA COUNTY, OHIO ANTHONY J. RUSSO, Presiding Judge LAURA J. GALLAGHER, Judge ESTATE OF _______________________________________________________________, DECEASED CASE NO. __________________________________ SURVIVING SPOUSE, CHILDREN, NEXT OF KIN, LEGATEES AND DEVISEES (R.C. 2105.06, 2106.13 2107.19) [Use with those applications or filings requiring some or all of the information in this form, for notice or other purposes. Update as required.] The following are decedent’s known surviving spouse, children, and the lineal descendants of deceased children. If none, the following are decedent’s next of kin who are or would be entitled to inherit under the statutes of descent and distribution. Name Residence Address Relationship to Decedent Birthdate of Minor Surviving Spouse [Check whichever of the following is applicable] 9 The surviving spouse is the natural or adoptive parent of all of the decedent’s children. 9 The surviving spouse is the natural or adoptive parent of at least one, but not all of decedent’s children. 9 The surviving spouse is not the natural or adoptive parent of any of the decedent’s children. 9 There are minor children of the decedent who are not the children of the surviving spouse. 9 There are minor children of the decedent and no surviving spouse. FORM 1.0 - SURVIVING SPOUSE, CHILDREN, NEXT OF KIN, LEGATEES AND DEVISEES 01/02 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. _______________________________ The following are the vested beneficiaries named in the decedent’s Will: Name Residence Address Birthdate of Minor [Check whichever of the following is applicable] 9 The Will contains a charitable trust or a bequest or devise to a charitable trust, subject to R.C. 109.23 to 109.41. 9 The Will is not subject to R.C. 109.23 to 109.41 relating to charitable trusts. _________________________________ ____________________________________________________________________ Date Applicant (or give other title) ____________________________________________________________________ American LegalNet, Inc. www.FormsWorkflow.com PROBATE COURT OF CUYAHOGA COUNTY, OHIO ANTHONY J. RUSSO, Presiding Judge LAURA J. GALLAGHER, Judge ESTATE OF _____________________________________________________________, DECEASED CASE NUMBER:______________________________________ ASSETS AND LIABILITIES OF ESTATE TO BE RELIEVED FROM ADMINISTRATION Following is a summary statement of the character and value of the assets in decedent’s estate [Insert a check in the “Appraised” column opposite an item if it was valued by the appraiser. Leave blank if the readily ascertainable value of the item was deter-mined by applicant. Use extra sheets if necessary.] __________________________________________________________________________________ Automobiles distributed to surviving spouse by affidavit Value ___________________________________________________________________________________ First automobile selected by surviving spouse under R.C. 2106.18 [Omit value when computing total assets] ------------------Appraised value $ XXXX Second automobile selected by surviving spouse under R.C. 2106.18 [Omit value when computing total assets] ------------------Appraised value $ XXXX Total value [not to exceed $40,000.00] Character of asset Real Estate, described in accompanying Certificate of Transfer No. $ Appraised XXXX Value $ ____________________________________________________________________________________ Other assets $ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ __________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Total Assets $ ____________________________________________________________________________________ FORM 5.1 - ASSETS AND LIABILITIES OF ESTATE TO BE RELIEVED FROM ADMINISTRATION 01/00 American LegalNet, Inc. www.FormsWorkflow.com Following is a list of decedent’s known debts. [Use extra sheets if necessary] ___________________________________________________________________________________ Name of creditor Nature of Debt Amount ____________________________________________________________________________________ $ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Total Debts $ CERTIFICATION The undersigned appraiser agreed to act as appraiser of decedent’s estate, and to appraise the property exhibited truly, honestly, impartially, and to the best of the appraiser’s knowledge and ability. The appraiser further says that those assets whose values were not readily ascertainable are indicated above by a check in the”Appraised” column opposite each such item, and that such values are correct. The undersigned applicant determined the value of those assets whose values were readily ascertainable and were not appraised by the appraiser, and that such values are correct, and to applicant’s knowledge the above list of decedent’s debts is correct. ____________________________________ Date ____________________________________ Appraiser ____________________________________ Applicant American LegalNet, Inc. www.FormsWorkflow.com PROBATE COURT OF CUYAHOGA COUNTY, OHIO ANTHONY J. RUSSO, Presiding Judge LAURA J. GALLAGHER, Judge ESTATE OF ____________________________________________________________________, DECEASED CASE NUMBER:____________________________ ENTRY RELIEVING ESTATE FROM ADMINISTRATION [R.C. 2113.03] Upon hearing the application to relieve decedent s estate from administration, the Court finds that: Decedent died [check one of the following] - 9 testate - 9 intestate. The date of death and domicile are as stated in the application, and the Court has jurisdiction over the estate; Notice to the surviving spouse, heirs at law, legatees and devisees, was duly effected or dispensed with by the Court as unnecessary; The values of the several assets in the estate, given in the application do not exceed the statutory limits. The Court therefore relieves the estate from administration, and orders [check and complete whichever of the following are applicable]: 9 That the following personal property be sold [describe]: ____________________________________________________________________________________________ ____________________________________________________________________________________________ 9 That the debts of decedent listed in the application be paid. ____________________________________________________________________________________________ ____________________________________________________________________________________________ 9 That the statutory family allowance be paid to the 9 surviving spouse - 9 minor children of the decedent 9 apportioned between the surviving spouse and minor children of the decedent who are not the children of the surviving spouse. 9 That Certificate of Transfer No. __________, attached to the application and describing decedent s real estate, issue and be preserved in the records of the Court and that authenticated copies of the certificate be delivered as required to the persons entitled to them; 9 That the financial institutions holding accounts in decedent s name as set forth below pay the same upon proper tax release [check one of the following] - 9 to the commissioner - 9 to ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ FORM 5.6 - ENTRY RELIEVING ESTATE FROM ADMINISTRATION 01/00 American LegalNet, Inc. www.FormsWorkflow.com 9 That the remainder of the estate be distributed in cash or in kind, as follows: _________________________________________________________________________________________________________ Name of Distributee Property Value or Amount $ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ The Court appoints _________________________________________________________________________________ commissioner, to receive and sell or distribute the personal property or proceeds thereof, and to execute all necessary documents of conveyance, including without limitation those necessary to transfer title to any motor vehicle, motorcycle, watercraft, or other titled personal property sold or distributed in kind. The commissioner shall complete the duties and report to the Court within sixty days of the date of this entry. _______________________________________________ Date _____________________________________________ PROBATE JUDGE American LegalNet, Inc. www.FormsWorkflow.com PROBATE COURT OF CUYAHOGA COUNTY, OHIO ANTHONY J. RUSSO, Presiding Judge LAURA J. GALLAGHER, Judge ESTATE OF _______________________________________________, DECEASED CASE NUMBER ______________________________________ NOTICE TO ADMINISTRATOR OF ESTATE RECOVERY PROGRAM [R.C. 2117.061] The undersigned gives notice to the Administrator of the Estate Recovery Program that the decedent was fifty-five (55) years of age or older at the time of death and has been determined to have been a recipient of medical assistance under Chapter 5111 of the Revised Code. ______________________________________________ 9 Executor 9 Administrator 9 Commissioner 9 Person who filed pursuant to 2113.03 of the Revised Code for release from administration CERTIFICATE OF SERVICE This is to certify a true copy of the above notice was served by certified U.S. mail, postage prepaid to the Administrator of the Estate Recovery Program, on ______________________ day of _______________________, 20______ . __________________________________ Person Responsible for the Estate __________________________________ Typed or Printed Name __________________________________ Address __________________________________ City, State, Zip Code __________________________________ Phone Number (include Area code) Form 7.0 - Notice to Administrator of Estate Recovery Program 10/03 American LegalNet, Inc. www.FormsWorkflow.com