IN THE CHANCERY COURT FOR WILLIAMSON COUNTY, TENNESSEE ESTATE OF: _______________________________ ) (Decedent) ) NO._______ STATEMENT IN LIEU OF ACCOUNTING The undersigned, being the Personal Representative of the Estate herein, pursuant to T.C.A. § 30-2-601(b)(1) and (c), states that the Personal Representative has: 1. Properly administered the Estate of the Decedent; 2. Has paid or settled all claims lawfully presented; 3. Has paid all expenses of administration; 4. Has mailed or delivered notice of the requirement to file claims, as prescribed in § 30-2-306(d), to the creditors of the decedent who were known to me or reasonably ascertainable. 5. Has filed with the Clerk the final receipt and release from the Tennessee Department of Revenue evidencing payment of all Tennessee inheritance and/or estate tax or waiver thereof; 6. Has filed a release from the Bureau of TennCare if required by law; 7. Has distributed the estate according to the laws of intestate succession. ___________________________________ PERSONAL REPRESENTATIVE STATE OF _____________________________ COUNTY OF ___________________________ Personally appeared before me, the undersigned, a Notary Public/Clerk & Master in and for said county and state, _____________________________________, with whom I am personally acquainted or proved to me on the basis of satisfactory evidence, and who acknowledged that the foregoing was executed for the purpose contained therein. This ____ day of ______________, 20______. My Commission Expires: _________ ____________________________________ NOTARY PUBLIC/CLERK & MASTER American LegalNet, Inc. www.FormsWorkFlow.com