Fill - Free fillable DO NOT LEAVE ANY ITEMS BLANK (NYS Unified Court System Division of Technology) PDF form

For Office Use Only

Filing Fee Paid $ _____________________

____________ Certs: _________________

$ ___________ Bond, Fee: _____________

Receipt No: ________ No:______________

DO NOT LEAVE ANY ITEMS BLANK

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF ______________________________

______________________________________________X

LETTERS OF ADMINISTRATION d.b.n.

ESTATE OF __________________________________

a/k/a ______________________________________

Deceased.

______________________________________________X

PETITION FOR

LETTERS OF ADMINISTRATION d.b.n.

SCPA 1007

[ ] Letters of Administration d.b.n.

[ ] Letters of Administration d.b.n. with

Limitations

[ ] Limited Letters of Administration d.b.n.

File No.______________________________

TO THE SURROGATE’S COURT, COUNTY OF _____________:

It is respectfully alleged:

1. (a) The name, citizenship, domicile (or, in the case of a blank or trust company, its principal office) and

interest in this proceeding of the petitioner(s) is/are as follows:

Name: __________________________________________________________________________________________

________________________________________________________________________________________________

Dom icile or Principal Office: (Street and Number) (City, Village or Town)

_______________________________________________________________________________________

(County) (State) (Zip Code) (Telephone Number)

Mailing Address: __________________________________________________________________________________________

(If different from domicile)

Citizenship (Check one): [ ] U.S.A. [ ] Other (specify)

Nam e: _________________________________________________________________________________________________

(Street and Number) (City, Village or Town)

_______________________________________________________________________________________________________

(County) (State) (Zip Code) (Telephone Number)

Domicile or Principal Office: _________________________________________________________________________

Mailing Address:

___________________________________________________________________________

(If different from domicile)

Citizenship (Check one): [ ] U.S.A. [ ] Other (specify)

Interest (s) of Petitioner (s): [Check one]

[ ] Distributee of decedent (state relationship) ________________________________________________

[ ] Other [Specify] ______________________________________________________________________

1. (b) Is the proposed Administrator d.b.n. an attorney? Yes [ ] No [ ]

[NOTE: If yes, submit statement pursuant to 22 NYCRR 207.16(e); see also 207.52]

2. Letters of Administration of the above-named decedent were issued by this court on

________________, to _______________________, who on __________________

[ ] died [ ] resigned [ ] was removed.

ADM/DBN-1 (7/98)

-1-

Yates

New York

[Note: For paragraphs 3a through c: Do not include any assets that are jointly held, held in trust for another, or

have a named beneficiary.]

3. (a) The estimated gross value of unadministered personal property passing by intestacy is less than

$ _________________.

(b) The estimated gross value of the decedent’s unadministered real property, in this state, which is

[ ] improved [ ] unimproved, passing intestacy is less then

$ _________________.

A brief description of each parcel is as follows:

__________________________________________________________________________________

(c) The estimated gross rent for a period of eighteen (18) months is the sum of

$ _________________.

(d ) In addition to th e value of th e pe rso nal prope rty stated in para gra ph (3) (a), the follo wing rig ht of ac tion e xisted

on behalf of the decedent and survived his/her death, or is granted to the administrator of the decedent by

special provision of law, and it is impractical to give a bond sufficient to cover the probable amount to be

recovered therein: (Write “NONE” or state briefly the cause of action and the person against who it

exists, including names and carrier].

(e) If decedent is survived by a spouse and a parent, or parents but no issue, and there is a claim for wrongful

death, check here [ ] and furnish names (s) and address (es) of parent (s) in paragraph 5.

See EPTL 5-4.4.

4. The decedent left surviving the following who would inherit his/her estate pursuant to EPTL 4-1.1 and

4-1.2:

a. Spouse (husband/wife). Divorced [Attach copy of Divorce Decree]

b. Child or children or descendants of predeceased child or children, [Must include marital,

non-marital, and adopted].

c. Any issue of the decedent adopted by persons related to the decedent (DRL Section 117).

d. Mother/Father.

e. Sisters and brothers, either of whole or half blood, and issue of predeceased sisters and brothers.

f. Grandmother/Grandfather.

g. Aunts or uncles, and children of predeceased aunts and uncles (first cousins).

h. First cousins once removed (children of first cousins).

[Information is required only as to those classes of relatives who would take the property of decedent pursuant to EPTL

4-1.1. State “numbers” of survivors in each class. Insert “NO” in all prior classes. Insert “X” in all subsequent classes].

-2-

-

5. The decedent left surviving the following distributees, or other necessary parties, whose nam es, degrees of

relationship, domiciles, post office addresses and citizenship are as follows:

[Note: Show clearly how each person is related to decedent. If relationship is through an ancestor who is deceased,

give name, date of death, and relationship of the ancestor to the decedent. Use rider sheet if space in Paragraph (5)

is not sufficient. See Uniform Rules 207.16 (b). If any person listed in paragraph (5) is a nonmarital person, or

descended from a nonmarital person, attach a copy of the order of filiation or Schedule A. If any person listed in

paragraph (5) was adopted by any persons related by blood or marriage to decedent or descended from such

persons, attach Schedule B.]

5a. The following are of full age and under no disability: [If nonmarital or adopted-out person, so indicate by

attaching Schedule A and/or B. If any of the distributees have died subsequent to the death of the decedent, give the name

and title of the legal representative appointed for such person (s), his or her address and the court that issued such letters.

If any distributee who has died, subsequent to the death of the decedent, has no legal representative, then enter the name,

relationship, domicile address and citizenship of that deceased person (s) distributee (s).]

Name Relationship Domicile and Citizenship

Mailing address

___________________ ___________________ ______________________ ___________________

5b. The following are infants and/or persons under disability: [Attach applicable Schedule A, B, C and/or D]

Name Relationship Domicile and Citizenship

Mailing address

___________________ ___________________ ______________________ ___________________

___________________ ____________________ ______________________ ___________________

-3-

6. There are no persons interested in this proceeding other than those herein mentioned.

7. There are no outstanding debts or funeral expenses, except: [Write “NONE” or state same]

__________________________________________________________________________________________

WHEREFORE, your petitioner (s) respectfully pray (s) that: [Check and complete all relief requested]

( ) a. Process issue to all necessary parties to show cause why letters should not be issued as requested;

( ) b. An order be granted dispensing with service of process upon those persons named in paragraph 5

who have a right to letters prior or equal to that of the person nominated, and who are

non-domiciliaries or whose names or whereabouts are unknown and cannot be ascertained;

( ) c. A decree award Letters of Administration d.b.n. to ____________________________________

____________________________________________________________________________

or to such other person or persons having a prior right as may be entitled thereto, and;

( ) d. That the authority of the representative under the foregoing Letters be limited with respect to the

prosecution of a cause of action on behalf of the estate, as follows: the administrator (s) may not

enforce a judgment or receive any funds without further order of the Surrogate.

( ) e. That the authority of the representative under the foregoing Letters be limited as follows:

_____________________________________________________________________________

( ) f. [State any other relief requested]. __________________________________________________

_____________________________________________________________________________

Dated:_______________________________________

1. _______________________________________ 2. _______________________________________

(Signature of Petitioner) (Signature of Petitioner)

_ _____ _

(Print Name) (Print Name)

3. _______________________________________

(Name of Corporate Petitioner)

(Signature of Officer)

_______________________________________

(Print Name and Title of Officer)

-4-

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF ___________________________

_________________________________________X

LETTERS OF ADMINISTRATION d.b.n.

ESTATE OF _______________________________

a/k/a ___________________________________

Deceased.

X

SCHEDULE A

NONMARITAL PERSONS

(PERSONS BORN OUT OF WEDLOCK)

File No. ________________________________

[NOTE: Nonmarital children (or their issue) who would be distributees if they (or their ancestors) were born in wedlock will

not be regarded as distributees unless satisfactory proof is submitted establishing paternity]. See EPTL 4-1.2, which sets

forth methods of establishing paternity.

Name of alleged distributee: ________________________________________________________________

Date of birth: ____________________ Relationship to decedent: ____________________________________

Name of father: ____________________________________________________________________________________

Name of mother: _____________________________________________________________________________

Does the birth certificate contain the father’s name? Yes [ ] No [ ]

If yes, attach a copy of birth certificate.

Has an order of filiation establishing paternity been entered?

Yes [ ] No [ ] If yes, attach a copy of order.

Did the nonmarital person live with his or her father? Yes [ ] No [ ]

If yes, give dates and place of residence: __________________________________________________

__________________________________________________________________________________________

-5-

Yates

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF ______________________________

X

LETTERS OF ADMINISTRATION d.b.n.

ESTATE OF ____________________________________

a/k/a _____________________________________

Deceased.

______________________________________________X

SCHEDULE B

ISSUE OF THE DECEDENT

WHO WERE THE SUBJECT OF AN ADOPTION

File No: ______________________________

Name of child: ______________________________________________________________________________

Relationship to decedent prior to adoption: _______________________________________________________

Date of adoption: ___________________________________________________________________________

Was this a ste-parent adoption? (i.e., was the child adopted by the spouse of the decedent’s former spouse?)

Yes [ ] No [ ]

If yes, name of adoptive father or mother: _________________________________________

If not a step-parent adoption, indicate below the biological relationship of the adoptive parent to the child:

[ ] grandparents (s)

[ ] brother or sister

[ ] aunt or uncle

[ ] first cousin

[ ] nephew or niece

Name of the adoptive parent __________________________________________________________________________

-6-

Yates

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF _______________________________

X

LETTERS OF ADMINISTRATION d.b.n.

ESTATE OF ___________________________________

a/k/a _______________________________________

Deceased.

______________________________________________ X

SCHEDULE C

INFANTS

File No. ______________________________

Name: _______________________________________________ Date of birth: _______________________

Relationship to the decedent: _________________________________________________________________

With whom does the infant reside? ____________________________________________________________

Name of mother: ________________________________________ Is she alive? ________________________

Name of father: Is he alive?

Does the infant have a court-appointed guardian? Yes [ ] No [ ]

If yes, name and address of guardian:

Name: Date of birth:

Relationship to the decedent:

With whom does the infant reside?

Name of mother: Is she alive?

Name of father: Is he alive?

Does the infant have a court-appointed guardian? Yes [ ] No [ ]

If yes, name and address of guardian:

-7-

Yates

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF _______________________________

X

LETTERS OF ADMINISTRATION d.b.n.

ESTATE OF ____________________________________

a/k/a ________________________________________

Deceased.

X

SCHEDULE D

PERSONS UNDER DISABILITY

OTHER THAN INFANTS

File No.

[Use additional sheets if needed]

1. Name: Relationship:

Residence:

With whom does this person reside?

If this person is in prison, name of prison:

Does this person have a court-appointed fiduciary? Yes [ ] No [ ]

If yes, give name, title and address:

If no, describe nature of disability:

If no, give name and address of relative or friend interested in his or her welfare:

2. Whereabouts unknown/Unknowns [persons whose addresses or names are unknown to petitioner; if known, give

name and relationship to decedent]: _____________________________________________________________

__________________________________________________________________________________________

-8-

Yates

COMBINED VERIFICATION, OATH & DESIGNATION

[For use when petitioner is to be appointed administrator d.b.n.]

STATE OF_________________)

COUNTY OF_______________) ss:

The undersigned, the petitioner named in the foregoing petition, being duly sworn, says:

1. VERIFICATION: I have read the foregoing petition subscribed by me and know the contents thereof,

and the same is true of my own knowledge, except as to the matters therein stated to be alleged upon information and belief,

and as to those matters I believe it to be true.

2. OATH OF ADMINISTRATOR d.b.n.: I am over eighteen (18) years of age and a citizen of the United

States; I will well, faithfully and honestly discharge the duties of the adm inistrator d.b.n.. I am not ineligible to receive letters.

3. DESIGNATION OF CLERK FOR SERVICE OF PROCESS: I do hereby designate the Clerk of the

Surrogate’s Court of County, and his or her successor in office, as a person on whom

service of any process issuing from such Surrogate’s Court may be made, in like manner and with like effect as if it were

served personally upon me, whenever I cannot be found within the State of New York after due diligence used.

My domicile is

(Street Address) (City/Town/Village) (State) (Zip Code)

(Signature of Petitioner)

(Print Name)

On , , before me personally came

to me known to be the person described in and who executed the foregoing instrument. Such person duly swore to such

instrument before me and duly acknowledged that he/she executed the same.

Notary Public

Commission Expires:

(Affix Notary Stamp or Seal)

Signature of Attorney:

Print Name:

Firm Name: Tel. No.:

Address of Attorney:

-9-

Yates

New York

COMBINED CORPORATE VERIFICATION, CONSENT AND DESIGNATION

[For use when a petitioner to be appointed is a bank or trust company]

STATE OF_________________)

COUNTY OF_______________) ss:

The undersigned, a of

(Title)

(Name of Bank or Trust Company)

a corporation duly qualified to act in a fiduciary capacity without further security, being duly sworn, says:

1. VERIFICATION: I have read the foregoing petitioner subscribed by me and know the contents

thereof, and the same is true of my own knowledge, except as to the matters therein stated to be alleged upon information

and belief, and as to those matters I believe it to be true.

2. CONSENT: I consent to accept the appointment as Administrator d.b.n. of the decedent described in

the foregoing petition and consent to act as such fiduciary.

3. DESIGNATION OF CLERK FOR SERVICE OF PROCESS: I do hereby designate the Clerk of the

Surrogate’s Court of County, and his or her successor in office, as a person on whom

service of any process issuing from such Surrogate’s Court may be made, in like manner and with like effect as if it were

served personally upon me, whenever I cannot be found within the State of New York after due diligence used.

(Name of Corporate Petitioner)

_______________________________________

(Signature of Officer)

_______________________________________

(Print Name and Title of Officer)

On the __________________________ , __________, before me personally came _______________________

to me known, who duly sworn to the foregoing instrument and who did say that he/she resides at ___________________

______________________ and that he/she is a ________________________________________________________ of

_______________________________the corporation/national banking association described in and which executed such

instrument, and the he/she signed his/her name thereto by order of the Board of Directors of the corporation.

_____________________________________

Notary Public

Commission Expires:

(Affix Notary Stamp or Seal)

Signature of Attorney:

Print Name:

Firm Name: Tel. No.:

Address of Attorney:

-10-

New York

Yates

LETTERS OF ADMINISTRATION d.b.n. CITATION File No.

SURROGATE’S COURT - ______________________COUNTY

CITATION

THE PEOPLE OF THE STATE OF NEW YORK,

By the Grace of God Free and Independent

TO ___________________________________________________________________________________________

___________________________________________________________________________________________

A petition having been duly filed by , who is

domiciled at

YOU ARE HEREBY CITED TO SHOW CAUSE before the Surrogate’s Court, _____________________ County,

at ________________________________________ , New York, on __________________________________, _______,

at o’clock in the noon of that day, why a decree should not be made in the estate

of ______________________________________________________________________________________________

lately domiciled at _________________________________________________________________________________

granting administration d.b.n. and directing that

[ ] Letters of Administration d.b.n. issue to: ___________________________________________________

[ ] Letters of Administration d.b.n. with Limitations issue to: ______________________________________

[ ] Limited Letters of Administration d.b.n. issue to : ____________________________________________

(State any further relief requested)

_________________________________________________________________________________________________

HON. ___________________________

Dated, Attested and Sealed, Surrogate

_________________________,______ ___________________________________________

(Seal) Chief Clerk

________________________________________________________________________________________________

Attorney For Petitioner Telephone Number

________________________________________________________________________________________________

Address of Attorney

[Note: This citation is served upon you as required by law. You are not required to appear. If you fail to appear it will be

assumed you do not object to the relief requested. You have a right to have an attorney appear for you.]

ADM/DBN-2 (7/98)

-11-

Yates

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF______________________________

_______________________________________________X

LETTERS OF ADMINISTRATION d.b.n.

ESTATE OF _____________________________________

a/k/a _________________________________________

Deceased.

_______________________________________________ X

WAIVER OF CITATION,

RENUNCIATION AND CONSENT

TO APPOINTMENT OF ADMINISTRATION d.b.n.

(INDIVIDUAL)

File No. _______________________

The undersigned, a distributee or creditor of the above-named decedent, and being of full age and sound mind, hereby

voluntarily appears in the Surrogate’s Court of _______________ County, New York, and waives the issuance and service

of citation in this matter, renounces all rights to Letters of Administration d.b.n. of the above captioned estate and consents

that

[ ] Letters of Administration d.b.n.

[ ] Letters of Administration d.b.n. with Limitations

[ ] Limited Letters of Administration d.b.n.

be issued to ______________________________________________________________________________________

or any other person or persons entitled thereto without any notice whatsoever to the undersigned, and consents

[ ] that a bond be dispensed with and hereby specifically releases any claim the undersigned might have

under any bond that may be filed.

[ ] that a bond in the amount of $ _________________________________be posted.

_______ _________________________ __________________________ ________________

Date Signature Street Address Relationship

_______ ________

Print Name Town/State/Zip

STATE OF NEW YORK

COUNTY OF ______________________ss.:

On __________________________________________ , _____________________, before me personally came

_________________________________________________________________________________________________

to me known and known to be the person described in and who executed the foregoing instrument. Such person duly swore

to such instrument before me and duly acknowledged that he/she executed the same.

___________________________________

Notary Public

Commission Expires:

(Affix Notary Stamp or Seal)

Name of Attorney: Tel. No.:

Address of Attorney:__

ADM/DBN-3 (10/04)

-12-

Yates

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF _________________________________

X

LETTERS OF ADMINISTRATION d.b.n.

ESTATE OF __________________________________

a/k/a ___________________________________

Deceased.

_______________________________________________ X

CONSENT TO APPOINTMENT OF

ADMINISTRATOR d.b.n.

(CORPORATION)

File No.___________________________

The undersigned corporation voluntarily appears in the Surrogate’s Court of _______________________ County,

New York, and consents that

[ ] Letters of Administration d.b.n.

[ ] Letters of Administration d.b.n. with Limitations

[ ] Limited Letters of Administration d.b.n.

be issued to ______________________________________________________________________________________

or any other person or persons entitled thereto without any notice whatsoever to the undersigned, and consents

[ ] that a bond be dispensed with and hereby specifically releases any claim the undersigned might have

under any bond that may be filed.

[ ] that a bond in the amount of $ ______________________________ be posted.

_________ _________________________________________

Date Name of Corporation

By: _________________________________________

(Signature of Officer)

__________________________________________

(Type Name and Title)

STATE OF NEW YORK

COUNTY OF _____________________ss.:

On __________________________________________ , _____________________, before me personally came

_________________________________________________________________________________________________

to me known, who being duly sworn did say that: (s)he resides at ____________________________________________

__________________________________________ of ____________________________________________________

the corporation described in and which executed the foregoing consent; and that (s)he signed the same thereto by order of

the board of directors of the above corporation.

___________________________________

Notary Public

Commission Expires:

(Affix Notary Stamp or Seal)

Name of Attorney: ________________________________________________ Tel. No.: _________________________

Address of Attorney:_

ADM/DBN-4 (10/04)

-13-

Yates

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF ________________________________

X

LETTERS OF ADMINISTRATION d.b.n.

ESTATE OF ____________________________________

a/k/a _________________________________________

Deceased.

_______________________________________________ X

NOTICE OF APPLICATION FOR

LETTERS OF ADMINISTRATION d.b.n.

(SCPA 1005)

File No. _________________________

Notice is Hereby Given That:

1. An application for Letters of Administration d.b.n. upon the estate of the above-named decedent, has been

made by __________________________________________________________ , petitioner, whose post office address

is: ______________________________________________________________________________________________

2. Each and every name of the intestate decedent known to the undersigned is as indicated in the above

caption.

3. Petitioner prays that a decree be made directing the issuance of Letters of Administration d.b.n. to

________________________________________________________________________________________________

4. The name and post office address of each and every distributee of the above-named decedent, as set

forth in the petition and known to the undersigned, are as follows:

(a). Distributees who have been duly cited, or have waived citation or have appeared in this proceeding:

Name of Distributee Domicile and Post Office Address

_____________________________________________ ____________________________________________

(b). Other Distributees:

Name of Distributee Domicile and Post Office Address

_____________________________________________ ____________________________________________

[IF MORE SPACE IS NEEDED ADD RIDER]

5. The undersigned does not know of any other distributees of the said decedent.

6. Letters of Administration d.b.n. will issue on or after _____________________ , ___________

Dated , ______________

Signature of Petitioner or Attorney

Print Name

Address

Name of Attorney: _________________________________________________ Tel. No.:_________________________

Address of Attorney:________________________________________________________________________________

ADM/DBN-5 (7/98)

-14-

Yates

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF ________________________________

X

LETTERS OF ADMINISTRATION d.b.n.

ESTATE OF ________________________________

a/k/a _____________________________________

Deceased.

_______________________________________________ X

AFFIDAVIT OF MAILING

NOTICE OF APPLICATION FOR

LETTERS OF ADMINISTRATION d.b.n.

(SCPA 1005)

File No. ______________________

STATE OF NEW YORK

COUNTY OF_________________________ ss.:

, residing at , New York, being duly

sworn, deposes and says that deponent is over the age of eighteen years; that on __________________, ________,

deponent mailed a copy of the foregoing Notice of Application for Letters of Administration d.b.n. , contained in a securely

closed postpaid wrapper, directed to each of the persons named in paragraph 4 (b), respectively, as follows:

whose post office address is __________________________________________________________________________

whose post office address is

whose post office address is __________________________________________________________________________

by depositing the document in a letters box or other official depository under the exclusive care and custody of the United

States Post Office located at:

_________________________________________________________________________________________________

________________________________

Signature

Sworn to before me this _____

day of ____________,_____________

______________________________

Notary Public

Commission Expires:

(Affix Notary Stamp or Seal)

ADM/DBN-6 (7/98)

-15-

Yates

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF _________________________________

X

LETTERS OF ADMINISTRATION d.b.n.

ESTATE OF ___________________________________

a/k/a _______________________________________

Deceased.

________________________________________________X

NOTICE TO THE CONSUL

GENERAL

File No. ___________________

TO THE CONSUL GENERAL OF _____________________

AT THE CITY OF NEW YORK

PLEASE TAKE NOTICE that a petition (will be) (has been) presented to the Surrogate’s Court, County of

__, on , , with respect to the Estate of the

above-named decedent, and it appears from the petition that:

a. the deceased was a subject of or

b. the following distributees are nonresidents of the United States:

Names Addresses Citizenship

_________________________ __________________________ _________________________

________________________________

Attorney for Petitioner

Address

Telephone Number

STATE OF NEW YORK

COUNTY OF _______________________ss.:

, being duly sworn, says:

That he/she resides at __________________________________________________________ , New York; that

on the ________________________________________________, _____________ , he/she served a copy of the above

NOTICE on the Counsel General of _____________________________________at ____________________________,

New York City, by mailing same to the office of the aforesaid Consul.

Sworn to before me this ______

day of ______________, _____

_____________________________

Notary Public

Commission Expires:

(Affix Notary Stamp or Seal)

ADM/DBN-7 (7/98)

-16-

Yates

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF ________________________________

X

LETTERS OF ADMINISTRATION d.b.n.

ESTATE OF ___________________________________

a/k/a ________________________________________

Deceased.

_______________________________________________ X

Note: File Proof of Service at least

3 days before return date. State

clearly date, time and place of

service and name of person served

(Uniform Rule 207.7 (c)).

AFFIDAVIT OF SERVICE

OF CITATION (Adult)

File No. ____________________

STATE OF NEW YORK : COUNTY OF____________________ss.:

................................................................................................ of ............................................................................................

......................................................, being duly sworn, says that I am over the age of eighteen years; that I made personal

service of the citation herein dated...................................................................., 20.......... on each person named below,

each of whom deponent knew to be the person mentioned and described in said citation, by delivering to and leaving with

each of them personally a true copy of said citation, as follows:

On .............................................................. , description, viz: sex ..................... , color of skin ............................................,

color of hair ........................................., approximate age .................. , weight .................... , height ............................., at

........................... o’clock.................m . on the............... day of ......................., 20........, at ................................................

.................................................................................................................................................................................................