DATE FILEDFORCOURT USE ONLY ALLOWANCE FOR SUPPORTRIGL 33-10-3PC-9.4 (Rev. 07/17) State of Rhode Island and Providence PlantationsProbate CourtPage 1 of 3 STATE OF RHODE ISLANDCounty ofEstate ofAlias PROBATE COURT OF THECity or Town ofNo. The undersigned,, spouse of said deceased, hereby request the court (name of petitioner)to make a reasonable allowance out of the estate for the support of deceased222s family. ()This request is for the (check one): First Period Second PeriodSignature ofPetitionerDate DECREE Allowance for the support of family in the amount of $is allowed, this, day of 20 .Entered:Name ofProbate JudgeDateSignature ofProbate JudgePer Order:Name ofProbate ClerkDateSignature ofProbate Clerk IGN HERE IGN HERE American LegalNet, Inc. www.FormsWorkFlow.com Exhibit AGross Income From All Sources Weekly Bi-Weekly Monthly Annuala.Gross Wages/ Salaryb.Overtime, Bonus, Commissionsc.Part-Time JobSubtotald.Dividendse.Interestf.Annuitiesg.Pensionsh.Retirement Fundsi.Social Securityj.Disabilityk.Unemployment Insurancel.Worker222s Compensationm.Public Assistance (welfare, etc.)n.Child Supporto.Alimonyp.Contributions from Household Membersq.Other:Total Gross IncomeExpenses Weekly Bi-Weekly Monthly Annual1.HousingRentMortgage Payment (Principle & Interest)Property TaxCondo FeeHome MaintenanceSnow Removal/Lawn CareOther:Total Housing Expenses2.UtilitiesHeating OilWood/Coal/PelletsPropane and Natural GasTelephone/Cell PhoneElectricityCable Television/InternetWater and SewerTrash CollectionOther:Total Utility ExpensesPC-9.4 (Rev. 07/17) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com 3.InsuranceHomeownerRenterVehicleHealth/Dental/VisionLifeDisabilityOther:Total Insurance Expenses4.Uninsured Health Care ExpensesMedicalDentalOrthodonticsEye Care/Glasses/Contact LensesPrescription DrugsTherapy and CounselingOther:Total Uninsured Health Care Expenses Additional Expenses Weekly Bi-Weekly Monthly Annual1.Children222s Expenses and ActivitiesChildren222s ClothingDiapersDay CareSchool Supplies, Tuition, SportsOther:Total Children222s Expenses2.Miscellaneous Financial ExpensesLoan PaymentsCredit CardsOther:Total Miscellaneous Financial ExpensesTotal Expenses Monthly Total Income:$Monthly Total Expenses:$Under penalty of perjury, I hereby swear the Statements contained in this document and any attachments are true and correct. NameSignature ofPartyDateNotary:Name of NotaryStateCountyOnday of, 20the petitioner, known to me or proved through satisfactory evidence, Signature ofNotaryDateCommission ID#Commission Expiration DateNotary SealPC-9.4 (Rev. 07/17) Page 3 of 3 IGN HERE IGN HERE American LegalNet, Inc. www.FormsWorkFlow.com