FORM CC-1681 (MASTER, PAGE ONE OF TWO) 07/19 STATEMENT IN LIEU OF SETTLEMENT OF Court File No. ........................................................................... ACCOUNT FOR DECEDENT222S ESTATE PURSUANT TO VIRGINIA CODE 247 64.2-1314 COMMONWEALTH OF VIRGINIA Circuit Court of ...................................................................................................................................................................................................................... Estate of ............................................................................................................................................................................................................. , Deceased. Date of death ..................................................................................................................................... Decedent died [ ] with [ ] without a will. Name of fiduciary ................................................................................................................................................................................................................. Name of other fiduciary ...................................................................................................................................................................................................... STATEMENT UNDER OATH Before me, the undersigned authority, on this day personally appeared the undersigned affiant(s) who, after being placed under oath by me, stated as follows: [Check the applicable alternative in Part 1.] 1.[ ] That the above-named Decedent died without a will, that I/we am/are the only distribute(s) of theDecedent222s estate, and that I/we serve as personal representative(s) of the estate,or [ ] That above-named Decedent died with a will, that I/we am/are the only residuary beneficiary(s) of the Decedent222s estate, and that I/we serve as personal representative(s) of the estate, 2.That all known charges against the Decedent222s estate have been paid, and 3.Specific bequests in Will distributed to (attach receipts):NAME DESCRIPTION OF BEQUEST ............................................................................................................................................ ....................................................................................... ............................................................................................................................................ ....................................................................................... ............................................................................................................................................ ....................................................................................... 4.That six months have elapsed since the personal representative(s) qualified in the Clerk222s Office. 5.In addition to the foregoing statements under oath, I (we) hereby certify and affirm that (choose one):A.[ ] On or before the date of filing this Statement with the Commissioner of Accounts, I(we) sent a copyof it by first class mail to every person entitled to a copy, pursuant to Virginia Code Section 64.2-1303, who made a written request therefor. The names and addresses of the persons to whom copies were sent and the dates they were mailed are shown on Page 2. OR B.[ ] No person entitled to a copy of this Statement pursuant to Virginia Code Section 64.2-1303 made awritten request therefor. 6.That the residue of the estate has been delivered to the distributees or beneficiaries. Signature Signature [ ] City [ ] County of ..................................................................[ ] City [ ] County of .................................................................. State/Commonwealth of: ............................................................... State/Commonwealth of: ............................................................... Subscribed and sworn to before me by Subscribed and sworn to before me by .................................................................................................................. ................................................................................................................. Date: ...................................................................................................... Date: ..................................................................................................... Notary Public ..................................................................................... Notary Public ..................................................................................... My commission expires: ................................................................ My commission expires: ................................................................ Registration No. ................................................................................ Registration No. ................................................................................ American LegalNet, Inc. www.FormsWorkFlow.com Certificate of Mailing I, the undersigned, do hereby certify that I have mailed a copy of the foregoing STATEMENT IN LIEU OF SETTLEMENT OF ACCOUNT FOR DECEDENT222S ESTATE to the following individuals on this the .............. day of ................................................ 20 ....... Executor/Administrator Executor/Administrator Executor/Administrator Name of Recipient Name of Recipient Address Address City State ZIP City State ZIP Name of Recipient Name of Recipient Address Address City State ZIP City State ZIP Name of Recipient Name of Recipient Address Address City State ZIP City State ZIP FORM CC-1681 (MASTER, PAGE TWO OF TWO) 07/02 American LegalNet, Inc. www.FormsWorkFlow.com