FORM SUMMARY Name of Form: Summary Assignment – Petition Form Number: PR-1840 Statutory Reference: §867.02, Wisconsin Statutes Benchbook Reference: PR-8 Purpose of Form: Used to initiate summary assignment of an estate. May include Special Administration. Who Completes It: Petitioner or attorney. Distribution of Form: Original to court. Accompanying Forms: New Form/Modification: Modification; last update 10/07. Modifications: Changed “Family Care Services” to “Family Care and/or Partnership benefits”. Added “Medicaid” after “Medical Assistance” (per Kathleen Emmerton, Estate Recovery). Comments: The Probate Claims Notice HCF13033 is used to give notice to the Wisconsin Department of Health and Family Services and the county clerk. 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: 04/24/2008 Page 1 American LegalNet, Inc. www.FormsWorkflow.com For Official Use COUNTY STATE OF WISCONSIN, CIRCUIT COURT, Amended IN THE MATTER OF Summary Assignment Petition with Special Administration Case No. UNDER OATH, I STATE THAT: , and date of death was County, State of 1. The decedent, whose date of birth was , died domiciled in post office address of: , with a . . 2. The petitioner is interested as 3. The estate of the decedent: qualifies for summary assignment without appointment of a personal representative. commenced under chapter 856, meets the requirements for termination under summary assignment of small estates. 4. The estate is one properly settled under summary assignment in that 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 cannot be summarily settled under §867.01, Wis. Stat. 5. After reasonable search: A. a will dated B. no will of the decedent has been found. has been filed or accompanies this petition. 6. A detailed statement of all property subject to administration including any encumbrance, lien, or other charge See attached upon each is as follows: Description of Property Value of Decedent’s Interest at Date of Death 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) $ PR-1840, 04/08 Summary Assignment - Petition ) §867.02, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com Summary Assignment - Petition Page 2 of 3 Case No. 7. The names and addresses of all creditors of the decedent or the decedent’s estate of whom the petitioner has knowledge and the amounts of their claims are as follows: Name of Creditor Address Claim Amount 8. The names and post-office addresses of all persons interested, so far as known to petitioner or ascertainable by the petitioner with reasonable diligence are as follows (indicate persons who are minors or otherwise under disability, and names and post-office addresses of their guardians): Name Relationship 9. The decedent: did not did did not did did did was did not did not was not Address Minor’s D. O. B. receive Medical Assistance/Medicaid. receive Family Care and/or Partnership benefits (through a Managed Care Organization – MCO/CMO). receive benefits from the Community Options Program (COP). receive benefits from Wisconsin Chronic Disease Program. 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: 10. If more than one spouse, see attached. If the decedent was ever married, complete the following: . deceased): Name of spouse ( living or Divorced from decedent at time of decedent’s death. Married to decedent did not receive benefits from the Community Options Program (COP). did The spouse did not receive benefits from the Wisconsin Chronic Disease Program. did The spouse 11. It is necessary to appoint a special administrator with the following powers: PR-1840, 04/08 Summary Assignment - Petition §867.02, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com Summary Assignment - Petition Page 3 of 3 Case No. BASED UPON THESE STATEMENTS, I REQUEST THAT THE COURT: 1. Assign the property to the persons entitled to it. 2. 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. 3. Order the transfer of interests in real estate, stocks or bonds registered in the name of the decedent, the title of a licensed motor vehicle, or any other form of property. 4. Order termination of any life estate. 5. Certify the right of survivorship of any joint tenant for which a certificate has not been issued. 6. Certify that any interest of the decedent in survivorship marital property vested in the surviving spouse at death. 7. Order termination of any estate commenced under Chapter 856, discharge the personal representative and cancel any bond. , whose address is 8. Appoint (name) as special administrator with the powers requested. Subscribed and sworn to before me on Signature of Petitioner Notary Public/Court Official Name Printed or Typed My commission expires: Address Telephone Number Name of Attorney Address Telephone Number Bar Number PR-1840, 04/08 Summary Assignment - Petition §867.02, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com