PROBATE COURT OF STARK COUNTY, OHIO DIXIE PARK, JUDGE ESTATE OF CASE NO. , DECEASED APPLICATION TO RELIEVE ESTATE FROM ADMINISTRATION [R.C. 21 13.03] Applicant states that decedent died on Decedent's domicile was Street Address County City or Village, or Township if unincorporated area Post Office State Zip Code [Check one of the following] Decedent's will has been admitted to probate in this Court. To applicant's knowledge, decedent did not leave a will. [Check one of the following] The assets are $15,000 or less and decedent died on or after January 1, 1976. The assets are $25,000 or less and decedent died on or after October 20, 1987. The assets are $35,000 or less and decedent died on or after November 9, 1994. The assets are $50,000 or less; the surviving spouse is entitled to all of the assets and the decedent died on or after April 16, 1993. The assets are $85,000 or less; the surviving spouse is entitled to all of the assets and the decedent died on or after September 14, 1993. The assets are $ 100,000 or less; the surviving spouse is entitled to all of the assets and the decedent died on or after March 18, 1999. [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 asks that the estate be relieved from administration because the assets do not exceed the statutory limits. A statement of the assets and liabilities of the estate is listed on the attached Form 5.1. The decedent's surviving spouse, next of kin, legatees, and devisees known to applicant, are listed on the attached Form 1.0. Attorney for Applicant Applicant Typed or Printed Name Typed or Printed Name Address Address Phone Number (include area code) Phone Number (include area code) Attorney Registration No. FORM 5.0 - APPLICATION TO RELIEVE ESTATE FROM ADMINISTRATION 8-19-11 American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. WAIVER OF NOTICE The undersigned surviving spouse, heirs at law, legatees, devisees, and other persons entitled to notice of the filing of the application to relieve decedent's estate from administration, waive such notice. ENTRY SETTING HEARING AND ORDERING NOTICE , at o'clock The Court sets date and time for hearing the application to relieve decedent's estate from administration. [Check one of the following] . M., as the All notice is dispensed with as unnecessary. Notice by publication to interested parties is dispensed with as unnecessary. Written notice shall be given, as provided by law and the Rules of Civil Procedure, to those persons entitled to notice, who have not waived notice. Written notice is dispensed with as unnecessary. as provided by law and the Rules of Civil Procedure. Notice by publication shall be given to interested parties Written notice shall be given to those persons entitled to notice, who have not waived notice, and notice by publication shall be given to interested parties, as provided by law and the Rules of Civil Procedure. Date Dixie Park, Probate Judge American LegalNet, Inc. www.FormsWorkFlow.com