FORM SUMMARY Name of Form: Summary Assignment - Affidavit Form Number: PR-1841 Statutory Reference: §867.02, Wisconsin Statutes Benchbook Reference: PR-8 Purpose of Form: Used to list in detail all property in which the decedent had an interest and name and address of all known creditors of the decedent or the estate. This form is only required when detailed information was not included on the petition. Who Completes It: Petitioner or attorney. Distribution of Form: Original to court. Accompanying Forms: New Form/Modification: Modification; last update 6/00. Modifications: Modified to comply with 2005 Wis. Act 216 Comments: About this Form: This form is the product of the Wisconsin Records Management Committee, a committee of the Director of State Court's Office and a mandate of the Wisconsin Judicial Conference. If you have additional information that does not change the meaning of the form, attach it on a separate page. The form itself shall not be altered. Date: 01/04/2007 Page 1 American LegalNet, Inc. www.FormsWorkflow.com For Official Use COUNTY STATE OF WISCONSIN, CIRCUIT COURT, Summary Assignment Affidavit IN THE MATTER OF THE ESTATE OF Case No. THIS INFORMATION IS NOT INCLUDED IN THE PETITION. UNDER OATH, I STATE THAT: 1. A detailed statement of all property, subject to administration including any encumbrance, lien, or other charge upon See attached. each is as follows: Value of Decedent’s Interest at Date of Death Description of Property A. Property Subject to Administration $ B. Encumbrances, liens or other charges upon each item: ($ C. Net value of Property Subject to Administration (Total value from Section A above less total from Section B above) ) $ 2. The names and addresses of all creditors of the decedent or the decedent’s estate of whom the petitioner has See attached. knowledge and the amounts of their claims are as follows: Name of Creditor Address Claim Amount Subscribed and sworn to before me on Signature of Petitioner Name Printed or Typed Notary Public/Court Official My commission expires: Address Telephone Number Name of Attorney Address Telephone Number Bar Number PR-1841, 01/07 Summary Assignment - Affidavit This form shall not be modified. It may be supplemented with additional material. §867.02, Wisconsin Statutes American LegalNet, Inc. www.FormsWorkflow.com