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For Ofce Use Only DO NOT LEAVE ANY (NYS Unified Court System Division of Technology)

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Page 1 of 18

For Ofce Use Only

Filling 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

ADMINISTRATION PROCEEDING, PETITION FOR LETTERS OF:

Estate of [ ] Administration

[ ] Limited Administration

a/k/a [ ] Administration with Limitations

[ ] Temporary Administration

Deceased File No. ________________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - X

TO THE SURROGATE’S COURT, COUNTY OF

____________________________________________________________________

It is respectfully alleged:

1. The name,domicile and interest in this proceeding of the petitioner,who is of full age,is as follows:

Name:

_______________________________________________________________________________________________

Domicile: _____________________________________________________________________________________________

(Street Address) (City/Town/Village)

_____________________________________________________________________________________________________

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

Mailing address is: ______________________________________________________________________________________

(if different from domicile)

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

Interest of Petitioner (check one):

[ ] Distributee of decedent (state relationship) ________________________________________________________________

[ ] Other(specify) ______________________________________________________________________________________

Is proposed Administrator an attorney? [ ] Yes [ ] No

[If yes, submit statement pursuant to 22 NYCRR 207.16(e); see also 207.52 (Accounting of attorney-duciary).]

The proposed Administrator [ ] is [ ] is not a convicted felon nor is he/she otherwise

ineligible, pursuant to SCPA 707 to receive letters.

If the proposed Administrator is a convicted felon,submit a copy of the Certicate of Relief from Civil Disabilities.

2. The name,domicile,date and place of death, and national citizenship of the above-named decedent are as follows:

[The Death Certicate must be led with this proceeding. If the decedent’s domicile is different from that shown on the death

certicate, check box [ ] and attach an afdavit explaining the reason for this inconsistency.]

Name: _______________________________________________________________________________________________

Domicile: _____________________________________________________________________________________________

(Street Number) (City,Village/Town)

_____________________________________________________________________________________________________

(State) (Zip Code)

Township of: __________________________________ County of: ________________________________________

Date of Death: __________________________________ Place of Death: ________________________________________

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

A1 (03/18)

Page 2 of 18

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

beneciary.]

3.(a) The estimated gross value of the decedent’s personal property passing by intestacy is less than

____________________________________________________

(b) The estimated gross value of the decedent’s real property, in this state, which is [ ] improved, [ ] unimproved, passing by

intestacy is less than

$ _____________________________________________________

A brief description of each parcel is as follows:

___________________________________________________________________________________________________________

(d) In addition to the value of the personal property stated in paragraph (3) the following right of action existed 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 sufcient to cover the probable amount to be recovered the rein: [Write“NONE or state briey the cause of action

and the person against whom 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 7. See EPTL5-4.4.

4. A diligent search and inquiry, including a search of any safe deposit box,has been made for a will of the decedent and none

has been found. Petitioner(s)(has)(have) been unable to obtain any information concerning any will of the decedent and therefore

allege(s),upon information and belief,that the decedent died without leaving any last will.

5. A search of the records of this Court shows that no application has ever been made for letters of administration upon the

estate of the decedent or for the probate of a will of the decedent, and your petitioner is informed and verily believes that no such

application ever has been made to the Surrogate’s Court of any other county of this state.

6. The decedent left surviving the following who would inherit his/her estate pursuant to EPTL4-1.1 and 4-1.2:

a. [ ] Spouse(husband/wife).

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

and adopted].

c. [ ] Any issue of the decedent adopted by persons related to the decedent (DRLSection117).

d. [ ] Mother/Father.

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

f. [ ] Grandmother/Grandfather.

g. [ ] Aunts or uncles, and children of predeceased aunts and uncles (rst cousins).

h. [ ] First cousins once removed (children of rst cousins).

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

EPTL4-1.1.State “number” of survivors in each class. Insert “No” in all prior classes. Insert “X” in all subsequent classes].

Page 3 of 18

7. The decedent left surviving the following distributees, or other necessary parties, whose names, degrees of relationship,

domiciles, post ofce address 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 (7) is not

sufcient. See Uniform Rules 207.16(b).

If any person listed in paragraph(7)is a non-marital person,or descended from an on marital person,attach a copy of

the order afliation or Schedule A. If any person listed in paragraph (7) was adopted by any persons related by blood or

marriage to decedent or descended from such persons, attach Schedule B].

7a. The following are of full age and under no disability:[If non-marital or adopted-out person,so indicate by attaching Schedule

A and/or B]

Name Relationship Domicile and Mailing Address

Country of Citizenship

___________________________ ________________________ _________________________ ________________________

7b. The following are infants and/or persons under disability: [Attach applicable Schedule A, B, C, and/or D]

Name Relationship Domicile and Mailing Address

Country of Citizenship

___________________________ ________________________ _________________________ ________________________

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

___________________________________________________________________________________________________________

Page 4 of 18

9. There are no other persons interested in this proceeding other than those here in before mentioned.

WHEREFORE, your petitioner respectfully prays 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(7) 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 to _________________________________________________________________________________

[ ] Limited Administration to __________________________________________________________________________

[ ] Administration with Limitation to _____________________________________________________________________

[ ] Temporary Administration 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 forgoing Letters be limited with respect to the prosecution or

enforcement 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)

Page 5 of 18

STATE OF NEW YORK )

) ss:

COUNTY OF )

COMBINED VERIFICATION, OATH AND DESIGNATION

[For use when petitioner is to be appointed administrator]

I, the undersigned the petitioner named in the foregoing petition, being duly sworn, say:

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 there in stated to be alleged upon information and belief,and as to those matters I believe

it to be true.

2. OATH OF ADMINISTRATOR as indicated above: I am over eighteen (18) years of age and a citizen of the United States; and

I will well,faithfully and honestly discharge the duties of Administrator of the goods, chattels and credits of said decedent according to

law. I am not ineligible, pursuant to SCPA707,to receive letters and will duly account for all moneys and other property that will come

into my hands.

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

________________ County, and his/her successor in ofce, 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 and served within the State of New York after due diligence used.

My domicile is:

_______________________________________________________________________________________________

(Street/Number) (City,Village/Town) (State) (Zip)

___________________________________________________

Signature of Petitioner

On the _______________________ day of ________________________,20 _______________________, 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:

(Afx Notary Stamp or Seal)

Signature of Attorney:

___________________________________

Print Name: ____________________________________________

Firm Name: ____________________________________________ Tel.No.: __________________________________________

Address of Attorney: __________________________________________________________________________________________

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Page 6 of 18

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - X

PROCEEDING FOR SCHEDULE A

Estate of NONMARITAL PERSONS

(PERSONS BORN OUT OF WEDLOCK)

a/k/a

Deceased. File# _______________________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - X

[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 certicate contain the father’s name? Yes [ ] No [ ]

If yes, attach copy of birth certicate.

Has an order of liation establishing paternity been entered? Yes [ ] No [ ]

If yes, attach copy of order.

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

If yes, give dates and places of residence: ___________________________________________________________________

___________________________________________________________________________________________________________

Page 7 of 18

SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - X

PROCEEDING FOR SCHEDULE B

Estate of ISSUE OF THE DECEDENT

WHO WERE THE SUBJECT

a/k/a OF AN ADOPTION

Deceased. File # _______________________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - X

Name of child:

_________________________________________________________________________________________

Relationship to decedent prior to adoption: __________________________________________________________________

Date of adoption: _______________________________________________________________________________________

Was this a step-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:

[ ] grandparent(s)

[ ] brother or sister

[ ] aunt or uncle

[ ] rst cousin

[ ] nephew or niece

Name of the adoptive parent: ___________________________________________________________________________________

Page 8 of 18

SURROGATE’S COURT OF THE STATE OF NEW YORK

COUNTY OF

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - X

PROCEEDING FOR SCHEDULE C

Estate of INFANTS

a/k/a

Deceased. File # _______________________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - X

[NOTE: Please furnish all of the information requested, otherwise the petition may be rejected.]

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

If yes, name and address of guardian: _____________________________________________________________________