PROBATE COURT OF STARK COUNTY, OHIO DIXIE PARK, JUDGE ESTATE OF CASE NO. , DECEASED APPLICATION FOR AUTHORITY TO ADMINISTER ESTATE [R.C. 2109.02 and 2109.07] [For Executors and all Administrators; attach supplemental application for ancillary administration, if applicable] 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 Applicant asks to be appointed To applicant's knowledge, decedent of decedent's estate. [Check whichever of the following are applicable] A supplemental did not leave a Will Decedent's Will has been admitted to probate in this Court application for ancillary administration is attached. Attached is a list of the surviving spouse, children, next of kin, and legatees and devisees, known to applicant, which list includes those persons entitled to administer the estate. The estimated value of the estate is: Personal property ................................................................... $ Annual real property rentals ............................................................ $ Subtotal, personalty and rentals Real Property ........................................................ $ $ .......................................................................... ................................................................. Total estimated estate Applicant owes the estate The estate owes applicant $ ............................................................... $ ............................................................. $ [Check one of the following four paragraphs] Applicant says that decedent's Will requests that no bond be required, and therefore asks the Court to dispense with bond. Applicant is a trust company duly qualified in Ohio, and bond is dispensed with by law. FORM 4.0 - APPLICATION FOR AUTHORITY TO ADMINISTER ESTATE 8/19/11 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. Applicant is decedent's surviving spouse and is entitled to the entire net proceeds of the estate, or applicant is the next of kin entitled to the entire net proceeds of the estate and there is no will. Bond is dispensed with by law. Applicant offers the attached bond in the amount of $ [Check , if applicable] Decedent was fifty-five (55) years of age or older at the time of death and was a recipient of medical assistance under Chapter 5111 of the Revised Code. SPF 7.0 - Notice to Administrator of Estate Recovery Program has been filed. Applicant accepts the duties of fiduciary in the estate imposed by law, and such additional duties as may be required by the Court. Applicant acknowledges being subject to removal as fiduciary for failure to perform such duties as required, and also acknowledges being subject to criminal penalties for improper conversion of any property held as fiduciary. Attorney for Applicant Applicant Typed or Printed Name Typed or Printed Name Address Address Phone Number (include area code) Attorney Registration No. Phone Number (include area code) WAIVER OF RIGHT TO ADMINISTER [R.C. 2113.06] The undersigned, being persons entitled to administer decedent's estate, and whose priority of right to do so is equal or superior to that of applicant, hereby waive appointment to administer the estate. ENTRY SETTING HEARING AND ORDERING NOTICE . M. as the date and time for , at The Court sets o'clock hearing the application for authority to administer decedent's estate. The Court orders notice to take or renounce administration to be given those persons entitled to administer decedent's estate, whose priority of right to do so is equal or superior to that of applicant, and who have not waived appointment to administer the estate. Date Dixie Park - Probate Judge American LegalNet, Inc. www.FormsWorkFlow.com