Page 1 of 2 pages. PETITION FOR INTESTATE ADMINISTRATION Form 075P, Rev. 2017.10.13 IN THE CHANCERY COURT OF HAMILTON COUNTY, TENNESSEE PETITION FOR INTESTATE ADMINISTRATION P ART 2 P ROBATE D IVISION F ILE N 0 . I N T HE M ATTER OF T HE E STATE OF D E CEDENT 1. P ETITIONER ( S ) Relationship of P etitioner(s) to Decedent : 2 . D ECEDENT Decedent died on at the age of at Date City & State Decedent's residence at time of death was: , , Street and Number City State Zip Code 3 . P ERSONAL R EPRESENTATIVE ( 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 C OURT . 4 . H EIRS & D ISABILITY 4(a) Decedent222s heirs are : Name Age Relation Mailing Address Zip Code 4(b) Decedent222s heirs who are under a disability are: 4(c) There is/is not a Conservatorship/Guardianship matter, pending or resolved with Do cket No. : 5. VALUE Estimated fair market value of non-probate assets Personalty Realty in: assets to be administered Personalty Realty in: * Total e stimated gross value of this e state for Tenn. inheritance tax purposes * Realty is usually a non - probate asset unless specifically devised to the estate or required to be sold to pay debts. 6 . T ENN C ARE At time of death, was Decedent enrolled in TennCare? Yes No Unknown PREMISES CONSIDERED, PETITIONER(S) PRAY 1. That , upon giving bond as may be required by T.C.A. 247 30-1-201, be appointed personal representative(s) of Decedent's estate. The address(es) of personal representative(s) is/are: 2. That notice by publication be given for creditors of Decedent's estate requiring them to file their claims. T . C . A . 247 30 - 2 - 306(a) . not be given. T.C.A. 247 30 - 2 - 306(e ). 3. That th e C LERK & M ASTER qualify the p ersonal 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. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 pages. PETITION FOR INTESTATE ADMINISTRATION Form 075P, Rev. 2017.10.13 5. That the inventory be waived or that 60 days be allowed for its filing. T.C.A. 247 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. 247 30 - 2 - 301(b) (1)( B) . 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. 247 30 - 2 - 301(b)(5) . Petitioner(s) certify(ies) that Petitioner(s) is/are unaware of any paper, document, instrume nt, or codicil whi ch 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(s) also agrees to the waiver of bond and inventory. Petitioner Petitioner Address Address WE ARE SURETY FOR COSTS IN THIS CAUSE. Attorneys for Petitioner By BPR# Address Tel. N0. Fax N0. C HANCERY C OURT OF HAMILTON COUNTY TENNESSEE } Sworn to and subscribed before me this day of , 20. ROBIN L.MILLER, CLERK & MASTER By Deputy Probate Clerk M ASTER 222 S O RDER 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. 247 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. 247 30 - 2 - 301(a). Affidavit of Notice to each devisee or legatee: Waived 60 days to file affidavit. T. C. A. 247 30 - 2 - 301(b). Affidavit of Notice t o TennCare: N/A 60 days to file affidavit. T. C. A. 247 30 - 2 - 301(b)(5). This day of , 20. ROBIN L. MILLER, CLERK & MASTER IF REQUIRED UNDER THIS ORDER, THE INVENTORY, AFFIDAVIT OF NOTICE TO HEIRS AND NOTICE TO TENNCARE IS DUE , 20. FAILURE TO FILE ANY REQUIRED DOCUMENT CHECKED ABOVE SHALL RESULT IN A SHOW CAUSE HEARING IN THE OFFICE OF THE CLERK & MASTER ON , 20 AT 8:30 A.M., AND A BOND SHALL IMMEDIATELY BE REQUIRED OF THE PERSONAL REPRESENTATIVE. American LegalNet, Inc. www.FormsWorkFlow.com