Barbara G. Reilly Register of Wills of Bucks County, Pennsylvania INVENTORY Return Completed Form within nine (9) months of date of death COMMONWEALTH OF PENNSYLVANIA COUNTY OF BUCKS SS File Number: , (NAME(S)) Personal Representative(s) of the Estate of , deceased, depose(s) and say(s) that the items appearing in the following inventory include all of the personal assets wherever situate and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said inventory represents its fair value as of the date of the decedent’s death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this inventory. I verify that the statements made in this Inventory are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities. Attorney -- (Name) (Supreme Court I.D. No.)_________________ (Address) (Telephone) DATE OF DEATH LAST RESIDENCE ITEM NO. DESCRIPTION DECEDENT’S SOCIAL SECURITY NO. ALL FIGURES MUST BE TOTALED NOTE: DOLLAR VALUE The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative include the value of each item, but such figures should not be extended into the total of the Inventory. (See 20 Pa. C.S.§3301(b)) (See Reverse side for additional space) ALL FIGURES MUST BE TOTALED www.buckscounty.org RW-09 rev. (3/10) American LegalNet, Inc. www.FormsWorkFlow.com 1 ITEM NO. DESCRIPTION DOLLAR VALUE TOTAL (Attach additional sheets as needed) www.buckscounty.org RW-09 rev. (3/10) American LegalNet, Inc. www.FormsWorkFlow.com 2