IN THE CHANCERY COURT OF HAMILTON COUNTY, TENNESSEE PETITION FOR INTESTATE ADMINISTRATION PART 2 PROBATE DIVISION FILE N0. T.C.A. § 30-1-117 IN THE MATTER OF THE ESTATE OF DECEDENT ITEM 1. PETITIONER(S). Relationship of Petitioner(s) to Decedent: ITEM 2. PERSONAL REPRESENTATIVE(S). Petitioner(s) seek to have ________________________________________________________________________________ appointed as personal representative(s) for this estate and verily believe said person(s) stand ready, willing and qualified to undertake the office as required by law and will furnish bond as directed by the COURT. ITEM 3. DECEDENT. Decedent died on _____________ at the age of ______ at ______________________________________________________ Date City & State Decedent's residence at time of death was: ______________________________________________, _______________________________, ______________________ Street and Number City ITEM 4. TENNCARE. At time of death, was Decedent enrolled in TennCare? ITEM 5. HEIRS. The following are Decedent’s heirs: Name ITEM 6. DISABILITY. Age Relation State Yes No Mailing Address Zip Code Unknown Zip Code Those persons listed in Item 5 who are under disability are: Personalty Real Estate in: Estimated fair market value Personalty ITEM 7. 2 assets to be administered of VALUE. Real Estate in: * 3Total estimated gross value of this estate for Tenn. inheritance tax purposes *Real estate is a non-probate asset unless specifically devised to the estate or required to be sold to pay debts. PREMISES CONSIDERED, PETITIONER(S) PRAY 1. That, upon giving bond as may be required by T.C.A. § 30-1-201, _________________________________________________________________________ be appointed personal representative(s) of Decedent's estate. The address(es) of personal representative(s) is/are: 1 non-probate assets be given for creditors of Decedent's estate requiring them to file their claims. T.C.A. § 30-2-306(a). 2. That notice by publication not be given. T.C.A. § 30-2-306(e). 3. That the CLERK & MASTER qualify the personal representative(s) and issue letters of administration. 4. That if bond is required and if the inventory reveals the estate exceeds the amount as set out in this petition, the personal representative(s) be required to increase the bond accordingly. 5. That the inventory be waived or that 60 days be allowed for its filing. T.C.A. § 30-2-301(a). 6. That the affidavit to residuary distributes be waived or that 60 days be allowed for its filing. T. C. A. § 30-2-301(b)(1)(B). Page 1 of 2 pages. PETITION FOR INTESTATE ADMINISTRATION Form 075P, Rev. 2011.01.20 American LegalNet, Inc. www.FormsWorkFlow.com 7. That, for a decedent who was 55 years or older at time of death, the affidavit of notice to TennCare be filed within 60 days. T. C. A. § 30-2-301(b)(5). Petitioner(s) certify(ies) that Petitioner(s) is/are unaware of any paper, document, instrument, or codicil which may be a Will of Decedent. The facts averred in this petition are true to the best knowledge, information, and belief of Petitioner(s). _____________________________________ _____________________________________ Petitioner Petitioner _____________________________________ _____________________________________ Address Address _____________________________________ _____________________________________ _____________________________________ _____________________________________ Petitioner Petitioner _____________________________________ _____________________________________ Address Address _____________________________________ _____________________________________ WE ARE SURETY FOR COSTS IN THIS CAUSE. CHANCERY COURT OF HAMILTON COUNTY TENNESSEE ___________________________________________________________ Attorneys for Petitioner By_____________________________________________ } Sworn to and subscribed before me BPR# this ____ day of ______________, 20___. ___________________________________________________________ Address S. LEE AKERS, CLERK & MASTER ___________________________________________________________ By________________________________________ ___________________________________________________________ Tel. N0. Fax N0. Deputy Probate Clerk MASTER’S ORDER From an examination of Petitioner(s) and witnesses under oath it appears the facts stated in the petition are true, and to the best knowledge of Petitioner(s), the estimated gross value of this estate for inheritance tax purposes is $______________, and that after proper qualification and pursuant to T. C. A. § 16-16-201 letters are to be issued to: _____________________________________________________________________________________________________ Bond: Waived Set at $ Inventory: Waived 60 days to file accurate inventory of the probate estate. T.C.A. § 30-2-301(a). Affidavit of Notice to each devisee or legatee: Waived 60 days to file affidavit. T. C. A. § 30-2-301(b). Affidavit of Notice to TennCare: N/A 60 days to file affidavit. T. C. A. § 30-2-301(b)(5). This ____ day of ____________________, 20___. ____________________________________________ S. LEE AKERS, CLERK & MASTER Page 2 of 2 pages. PETITION FOR INTESTATE ADMINISTRATION Form 075P, Rev. 2011.01.20 American LegalNet, Inc. www.FormsWorkFlow.com