PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, JUDGE ESTATE OF , DECEASED CASE NO. SURVIVING SPOUSE, CHILDREN, NEXT OF KIN, LEGATEES AND DEVISEES [R.C. 2105.06, 2106.13 and 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 the 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] The surviving spouse is the natural or adoptive parent of all of the decedent's children. The surviving spouse is the natural or adoptive parent of at least one, but not all, of the decedent's children. The surviving spouse is not the natural or adoptive parent of any of the decedent's children. There are minor children of the decedent who are not the children of the surviving spouse. There are minor children of the decedent and no surviving spouse. Page 1 of 2 FORM 1.0 - SURVIVING SPOUSE, NEXT OF KIN, LEGATEES AND DEVISEES 12/01/02 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] This will contains a charitable trust or a bequest or devisee to a charitable trust, subject to R.C. 109.23 and 109.41. The will is not subject to R.C. 109.23 and 109.41 relating to charitable trusts. Date Page 2 of 2 Applicant (or give other title) FORM 1.0 - SURVIVING SPOUSE, NEXT OF KIN, LEGATEES AND DEVISEES 12/01/02 American LegalNet, Inc. www.FormsWorkflow.com