PROBATE COURT OF STARK COUNTY, OHIO DIXIE PARK, JUDGE ESTATE OF CASE NO. , DECEASED 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. [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. 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 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 8-19-2011 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) Attorney Registration No. Phone Number (include area code) Signed and acknowledged by the applicant in my presence this , . day of Notary Public/Deputy Clerk American LegalNet, Inc. www.FormsWorkFlow.com