DATE FILEDFORCOURT USE ONLY Respectfully represents:Name of the DeceasedRI Personal Estate Estimated at $ UnknownResided inCity/Town/State Date of Death Petitioner:NameRelationship to DeceasedStreet AddressCity/TownStateZipCodePhoneNumberRespectfully requests:Name of NomineeRelationship toDeceasedStreet AddressCity/TownStateZipCodePhoneNumberName of Co-Nominee (if any)Relationship toDeceasedStreet AddressCity/TownStateZipCodePhoneNumberDeceased left the following surviving spouse and heirs at law:NAMERELATIONSHIPADDRESSSpouseForm PC-9.1, Waiver, if applicable. Petitioner: Signature of PetitionerDateNotary:Name of NotaryStateCountySignature of Notary PublicDateCommission ID#Commission Expiration DateNotary Seal ANCILLARY PETITION RIGL 33-7-21(ATTACH AUTHENTICATED COPIES OF ORIGINAL PROBATE FILE)PC-1.3 (Rev. 07/17) Probate CourtPage 1 of 2 STATE OF RHODE ISLANDCounty ofEstate ofAlias PROBATE COURT OF THECity or Town of American LegalNet, Inc. www.FormsWorkFlow.com Deceased left the following surviving spouse and heirs at law:NAMERELATIONSHIPADDRESSPC-1.3 (Rev. 07/17) Page 1A of 2 American LegalNet, Inc. www.FormsWorkFlow.com DECREEUpon hearing, it is hereby ordered and decreed:NameStreet AddressCity/TownStateZip CodeEmailPhone NumberNameStreet AddressCity/TownStateZip CodeEmailPhone Number executor co-executor other With Surety Without Surety Appointed APPRAISER(S)ORAppraiser NameStreet AddressCity/TownStateZip CodeEmailPhone NumberCo-Appraiser NameStreet AddressCity/TownStateZip CodeEmailPhone NumberAppointed RESIDENT AGENTResident Agent NameStreet AddressCity/TownStateZip CodeEmailPhone NumberEntered as an order and decree of the court on:Probate JudgeDateSignature of Probate JudgePC-1.3 (Rev. 07/17) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com