TED KLAMMER, JUDGE PROBATE COURT OF LAKE COUNTY, OHIO ESTATE OF ___________________________________________________________, DECEASED CASE NO. ______________________ APPLICATION FOR SUMMARY RELEASE FROM ADMINISTRATION [R.C. 2113.031] The 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] The applicant is decedent’s surviving spouse entitled to one hundred percent of the allowance for support and decedent’s funeral and burial expenses have been prepaid or the surviving spouse has paid or is obligated in writing to pay decedent’s funeral and burial expenses and the value of the assets does not exceed the $40,000 allowance for support under R.C. 2106.13(B) plus an amount not exceeding $5,000 for decedent’s funeral and burial expenses. The applicant, who is not surviving spouse, has paid or is obligated in writing to pay decedent’s funeral and burial expenses and the value of the assets is the lesser of $5,000 or the amount of decedent’s funeral and burial expenses. Attached hereto is a receipt, contract or other document that confirms the applicant to pay decedent’s funeral and burial expenses or if the applicant is the surviving spouse, the prepayment receipt, if applicable. The decedent’s surviving spouse, next of kin, legatees and devisees known to applicant, are listed on attached Form 1.0. Applicant states that there are no pending proceedings for the administration of decedent’s estate or relief of decedent’s estate from administration under R.C. 2113.03. All known assets with date of death values of the estate are as follows: Motor Vehicles (include year, make, model, body type, manufacturer’s vehicle identification number and Certificate of Title number) _________________________________________________________$_____________________ _______________________________________________________________________________ FORM 5.10-APPLICATION FOR SUMMARY RELEASE FROM ADMINISTRATION Eff. Date March 1, 2008 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO._________________ Accounts maintained by a Financial Institution (include financial institution name and the account’s complete identifying number: ___________________________________________________________$___________________ _______________________________________________________________________________ Stocks and Bonds (include for each stock or bond its serial number, the name of its issuer, the name and address of its transfer agent, and the total number of shares of stocks or bonds): ____________________________________________________________$__________________ _______________________________________________________________________________ Real estate described in accompanying Form 12.0 Application for Certificate of Transfer and Form 12.1 Certificate of Transfer and date of death value. [Attach verification of value] $_________ Other assets and date of death values _______________________________________________________________________________ ____________________________________________________________$__________________ Total Assets $_________ Applicant requests an order granting summary release. __________________________________ Attorney for Applicant __________________________________ Applicant’s Signature __________________________________ Typed or Printed Name __________________________________ Applicant’s Typed or Printed Name __________________________________ Street Address __________________________________ Street Address __________________________________ City State Zip Code __________________________________ City State Zip Code __________________________________ Phone Number (include area code) __________________________________ Phone Number (include area code) Attorney Registration No._____________ Signed and acknowledged by the applicant in my presence this ______day of_____________, 200__. __________________________________ Notary Public/Deputy Clerk FORM 5.10-APPLICATION FOR SUMMARY RELEASE FROM ADMINISTRATION--Eff. Date March 1, 2008 American LegalNet, Inc. www.FormsWorkFlow.com