PR-1835, 05/16 Petition for Summary Settlement (Formal Administration) 247247711.03(10) and 867.01, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF THE ESTATE OF N ame Amended Petition for Summary Settlement with Special Administration (Formal Administration) Case No. UNDER OATH, I STATE: 1. The decedent, with date of birth and date of death , was domiciled in County, State of , with a mailing address of . 2. The petitioner is interested as . 3. The estate of the decedent qualifies for summary settlement without appointment of a personal representative. was started under formal administration, meets the requirements for termination under summary settlement of small estates. 4. The estate is one properly settled under summary settlement in that (Select either A or B below.) A. the estate, less the amount of the debts for which any property in the estate is security, does not exceed in value the costs, expenses, allowances, and claims under 247859.25(1)(a) to (g), Wis. Stats. B. the estate, less the amount of the debts for which any property in the estate is security, does not exceed $50,000 in value and the decedent is survived by a spouse or domestic partner, or one or more minor children. 5. A detailed statement of all property subject to administration including any encumbrance, lien, or other charge against each is as follows: See attached Description of Property Include s real estate, stocks or bonds, licensed motor vehicles and all other property , including digital property as defined under 247 711.03(10), Wis. Stats. Value of Interest at Date of Death A. Total value of p ro perty subject to a dministration $ B. Minus total value of e ncumbrances, liens or other charges against each item of property ($ ) C. Net value of property subject to administration TOTAL $ (Value from Section A less total from Section B) American LegalNet, Inc. www.FormsWorkFlow.com PR-1835, 05/16 Petition for Summary Settlement (Formal Administration) 247247711.03(10) and 867.01, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 6. The decedent had a life estate or interest as a joint tenant or there is property which is security for a debt in which decedent had such interests for which a certificate has not been issued. Any real estate in which the decedent had this interest is described as follows: See attached Description of Property Include s real estate, stocks or bonds, licensed motor vehicles and all other property , including digital property as defined under 247 711.03(10), Wis. Stat s. 7. The names and mailing addresses of all creditors of the decedent or the estate of whom the petitioner has knowledge and the amounts of their claims are as follows: See attached Name of Creditor Mailing Address Claim Amount $ 8. The names and mailing addresses of all interested persons (including children of decedent who are not children of the surviving spouse or domestic partner), so far as known to petitioner or ascertainable by the petitioner with reasonable diligence are as follows: (For any person with disabilities, also list any guardian of estate; for any person in the military, also list attorney or attorney in fact; and for any minor, list date of birth.) See attached Name Relationship Mailing Address If Minor, Date of Birth 9. The decedent did did not receive Medical Assistance/Medicaid. did did not receive Family Care and/or Partnership benefits (through a Managed Care Organization MCO/CMO). did did not receive benefits from the Community Options Program (COP). did did not receive benefits from Wisconsin Chronic Disease Program. was was not a patient or inmate of a state or county hospital or institution, or responsible for any person owing an obligation to the state or county. Explain: The affiant lacks information to complete this section. 10. If the decedent was ever married, complete the following: (If more than one spouse, provide the same information on a separate page.) See attached Name of spouse [ living or deceased] . Married to decedent The spouse did did not receive benefits from the Community Options Program (COP). The spouse did did not receive benefits from the Wisconsin Chronic Disease Program. The affiant lacks information to complete this section. American LegalNet, Inc. www.FormsWorkFlow.com PR-1835, 05/16 Petition for Summary Settlement (Formal Administration) 247247711.03(10) and 867.01, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3 11. It is necessary to appoint a special administrator with the following powers: 12. Other: I REQUEST THE COURT: Assign the property to the persons entitled to it as follows: See attached Person(s) Entit led to Receive Description of Property (Include real estate, stocks or bonds, licensed motor vehicles and all other property (including digital property as defined under 247 711.03(10), Wis. Stats. ) Value $ 1. Order any person indebted to or holding money or other property of the decedent to pay the indebtedness or deliver the property to the persons found to be entitled to receive it. 2. Certify the termination of any life estate or the right of survivorship of any joint tenant in the property described. 3. Order termination of any estate commenced under Chapter 856, discharge the personal representative and cancel any bond. 4. Appoint [Name] , mailing address as special administrator with the powers requested. 5. Other: State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: Petitioner Name Printed or Typed Address Telephone Number Date Form completed by: (Name) Address Telephone Number Bar Number American LegalNet, Inc. www.FormsWorkFlow.com