PROBATE COURT OF SHELBY COUNTY, OHIO 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 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 $5,000.00 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 $5,000.00 or the amount of decedent’s funeral and burial expenses. Attached hereto is a receipt, contract or other document that confirms the applicant’s payment or obligation to pay decedent’s funeral and burial expenses or if the applicant is the surviving spouse, the pre-payment receipt, if applicable. The decedent’s surviving spouse, children, next of kin, legatees, and devisees known to the applicant, are listed on the 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): _____________________________________________________________________ $____________________ __________________________________________________________________________________________ Page 1 of 2 FORM 5.10 – APPLICATON 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 it’s 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 ____________________________________________ Attorney’s Typed or Printed Name ______________________________________ Applicant’s Typed or Printed Name ____________________________________________ Address ______________________________________ 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 _______________________, 20____. _____________________________________________ Notary Public/Deputy Clerk Page 2 of 2 FORM 5.10 – APPLICATON FOR SUMMARY RELEASE FROM ADMINISTRATION Eff. Date March 1, 2008 American LegalNet, Inc. www.FormsWorkflow.com