AFFIDAVIT FOR FILING IN PHILADELPHIA COUNTY BY FOREIGN FIDUCIARY Commonwealth of Pennsylvania } } County of } ss. being duly {sworn } {affirmed} depose and say as follows: I am We are {Executor {Administrator {Administrator c.t.a. {Trustee {Guardian } } } } } in the Estate of who was adjudicated incompetent who died (Date) (County) a resident of (City) (State) That deponent desires to exercise within the Commonwealth of Pennsylvania the authority vested in deponent by virtue of an Act of Assembly of the Commonwealth of Pennsylvania, known as the Probate, Estate and Fiduciaries Code of 1972, P.L. 164, Sec. 4101 (1) and (2), and has complied with all the provisions of same. That after diligent search and inquiry, deponent states that so far as deponent has been able to discover, the above ward / decedent is not indebted to any person in the Commonwealth of Pennsylvania; would not be permitted to exercise in the appointment. } } and subscribed to before } } } } } } } } } } } } } } } } } } } } and that deponent will not exercise any power which jurisdiction of Sworn Affirmed (Signature) me this day of (Address) A.D. 20 . (Signature) (Signature and seal of Notary or other official qualified to administer oaths Show date of expiration of Notary's commission) (Address) (If corporation affix corporation seal) DO NOT FILE THIS AFFIDAVIT UNTIL AFTER ONE MONTH FROM DECEDENT's DEATH. AN EXEMPLIFIED COPY OF PROBATE PROCEEDINGS MUST ACCOMPANY THIS FORM. APPENDIX A: Form 10 - Foreign Fiduciary Affidavit American LegalNet, Inc. www.USCourtForms.com