PROBATE COURT OF LUCAS COUNTY, OHIO JACK R. PUFFENBERGER, JUDGE ESTATE OF ______________________________________________________, DECEASED CASE NO. ______________________ APPLICATION FOR SUMMARY RELEASE FROM ADMINISTRATION [R.C. 2113.031] Applicant states that decedent died on _______________________________________________ Decedent's domicile was ________________________________________________________ Street address ______________________________________________________________________________ City or Village, or Township if unincorporated area Post Office State County 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 the 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 applicants payment or obligation 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) _____________________________________________________ $ ________________ _____________________________________________________ $ ________________ «FTU6/21O- (Page 1 of 2) 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 stock 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 ____________________________________ Typed or Printed Name ____________________________________ Street Address ____________________________________ City State Zip Code ____________________________________ Phone Number (include area code) Attorney Registration No. ______________ Signed and acknowledged by the applicant in my presence this ___ day of ___________, 20___. ____________________________________ Notary Public/Deputy Clerk (Page 1 of 2) FORM 5.10 ­ APPLICATION FOR SUMMARY RELEASE FROM ADMINISTRATION Eff. Date ­ March 1, 2008 American LegalNet, Inc. www.FormsWorkFlow.com ____________________________________ Applicant's Signature ____________________________________ Applicant's Typed or Printed Name ____________________________________ Street Address ____________________________________ City State Zip Code ____________________________________ Phone Number (include area code)