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
___________________________________________
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ADMINISTRATION PROCEEDING, PETITION FOR LETTERS OF:
Estate of [ ] Administration
[ ] Limited Administration
a/k/a [ ] Administration with Limitations
[ ] Temporary Administration
Deceased File No. ________________________________________
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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 decedents domicile is different from that shown on the death
certicate, check box [ ] and attach an afdavit 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:
___________________________________________________________________________________________________________
(c) The estimated gross rent for a period of eighteen (18) months is the sum of $ ____________________________________
(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 sufcient 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
sufcient. 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:
(Afx Notary Stamp or Seal)
Signature of Attorney:
___________________________________
Print Name: ____________________________________________
Firm Name: ____________________________________________ Tel.No.: __________________________________________
Address of Attorney: __________________________________________________________________________________________
click to sign
signature
click to edit
click to sign
signature
click to edit
Page 6 of 18
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
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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
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PROCEEDING FOR SCHEDULE B
Estate of ISSUE OF THE DECEDENT
WHO WERE THE SUBJECT
a/k/a OF AN ADOPTION
Deceased. File # _______________________________________________
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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
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PROCEEDING FOR SCHEDULE C
Estate of INFANTS
a/k/a
Deceased. File # _______________________________________________
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[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: _____________________________________________________________________
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: _____________________________________________________________________
Page 9 of 18
SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF
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PROCEEDING FOR SCHEDULE D
Estate of PERSONS UNDER DISABILITY
OTHER THAN INFANTS
a/k/a
Deceased. File # _______________________________________________
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[use additional sheets if more than one]
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 duciary? 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. Where abouts unknown/Unknowns [persons whose addresses or names are unknown to petitioner;if known,give name and
relationship to decedent]
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Page 10 of 18
ADMINISTRATION 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 led by _________________________________________________________ , who is domiciled at
___________________________________________________________________________________________________________
YOU ARE HERE BY CITED TO SHOW CAUSE before the Surrogate’s Court,
_______________________________________
County, at __________________ , New York, on ______________________ ,20 ____ at _________ o’clock in
the ________________________ noon of that day, why a decree should not be made in the estate of ________________________
___________________________________________________________________________________________________________
lately domiciled at ____________________________________________________________________________________________
in the County of
_________________________________________ ,New York, granting Letters of Administration upon the estate of
the decedent to
_________________________________________ or to such other person as may be entitled there to.
(State any further relief requested)
_________________________________________________
HON.
Dated, Attested and Sealed, __________________ , 20 ________ Surrogate
(Seal)
_________________________________________________
Chief Clerk
Name of
Attorney for Petitioner ____________________________________ Tel.No. ___________________________________________
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-at-law appear for you.
Page 11 of 18
SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF
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ADMINISTRATION PROCEEDING
Estate of NOTICE OF APPLICATION FOR
LETTERS OF ADMINISTRATION
(SCPA 1005)
a/k/a
Deceased. File No. ____________________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - X
Notice is Hereby Given That:
(1) an application for Letters of Administration upon the estate of the above-named decedent, has been made
by,
________________________________________________________________________________________________ petitioner,
whose post ofce 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 to
_________________________
_____________________________________________________________________________________________________
(4) the name and post ofce 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, have waived citation or have appeared in this proceeding:
Name of Distributee Domicile and Post Ofce Address
__________________________________________ __________________________________________
__________________________________________ __________________________________________
__________________________________________ __________________________________________
(b) Other Distributees;
Name of Distributee Domicile and Post Ofce Address
__________________________________________ __________________________________________
__________________________________________ __________________________________________
__________________________________________ __________________________________________
[CONTINUE ON REVERSE SIDE IF MORE SPACE NEEDED]
(5) That the undersigned does not know of any other distributees of the said decedent.
(6) That Letters of Administration will issue on or after
______________________ ,20 ________
Dated: _______________________ ,20 _________ __________________________________________
Signature of Petitioner or Attorney
__________________________________________ __________________________________________
Attorney for Petitioner Print Name
__________________________________________ __________________________________________
Address (Ofce) Address
__________________________________________
Tel No.
A-3
Page 12 of 18
SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF
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ADMINISTRATION PROCEEDING AFFIDAVIT OF MAILING
Estate of NOTICE OF APPLICATION FOR
LETTERS OF ADMINISTRATION
(SCPA 1005)
a/k/a
Deceased. File No._____________________
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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
_____________________
, 20
_______
deponent mailed a copy of the foregoing Notice of application for Letters of administration, contained in a securely closed postpaid
wrapper, directed to each of the persons named in paragraph 4(b), respectively, as follows:
whose post ofce address is
____________________________________________________________________________________
whose post ofce address is____________________________________________________________________________________
whose post ofce address is____________________________________________________________________________________
whose post ofce address is____________________________________________________________________________________
whose post ofce address is____________________________________________________________________________________
whose post ofce address is____________________________________________________________________________________
whose post ofce address is____________________________________________________________________________________
whose post ofce address is____________________________________________________________________________________
by depositing the document in a letter box or other ofcial depository under the exclusive care and custody of the United States Post
Ofce, located at:
___________________________________________________________________________________________________________
Sworn to before me this
__________________________________
_________________________________________________
day of_______________________________________
,20 ______________________________________
Signature
Notary Public
Commission Expires:
(Afx Stamp or Seal)
A-4
Page 13 of 18
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
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ADMINISTRATION PROCEEDING
Estate of NOTICE TO CONSUL
GENERAL
a/k/a
Deceased. File No _______________________________________________
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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 ______________,20 ___________________________ , 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 No.
STATE OF NEW YORK
COUNTY OF
_________________________________________ss.:
____________________________________ being duly sworn,says:
That he/she resides at
__________________ , New York; that on the
__________________________________________ ,20
________ , he/she served a copy of the above NOTICE on the Consul General
of
________________________________________ at _________ ,New York City,by mailing same to the ofce of the aforesaid Consul.
_________________________________
Signature
Sworn to before me this ______________________
day of _____________________________________ ,20 ________
______________________________________________________
Notary Public
Commission Expires: (Afx Stamp and Seal)
A-5
Page 14 of 18
At a Surrogate’s Court of the State of New York Held
in and for the County of
_______________________ ,
at
_________________________________New York
on
_______________________ ,20 _____________
PRESEN T:
HON.
_____________________________________
Surrogate.
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ADMINISTRATION PROCEEDING DECREE APPOINTING
Estate of ADMINISTRATOR
a/k/a FileNo. _______________________________________________
Deceased.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - X
A petition having been led by
_____________________________________________________________ praying that administration
of the goods, chattels and credits of the above-named decedent be granted to
___________________________________________ ;
and all persons named in such petition,required to be cited,having been duly cited to show cause why such relief should not be
granted or having duly waived the issuance of such citation and consented thereto; and it appearing
that
_______________________________________________________________________________________________________
is in all respects competent to act as administrat ____________________________________________of the estate of said deceased,
and a
[ ] bond having been led and approved in the amount of $ _____________________________________________________
[ ] bond having been dispensed with
and such representative(s) otherwise having qualied therefore; now, after due deliberation,with no one appearing in opposition
thereto, it is
ORDERED AND DECREED that Letters of Administration issue to
________________________________________________
___________________________________________________________________________________________________________
ORDERED AND DECREED, that the authority of such representative(s) be restricted in accordance with, and that letters herein
issued contain, the limitation, if any, which appears immediately below.
_________________________________
Surrogate
A-6
Page 15 of 18
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
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ADMINISTRATION PROCEEDING
Estate of AFFIDAVIT OF
REGULARITY
a/k/a
Deceased. File No. ______________________________________________
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STATE OF NEW YORK
COUNTY OF ss.:
__________________________________________ , being duly sworn, deposes and says:
1. That he/she is the attorney for
________________________________________________________________________ ,the
__________________________________________ herein.
2. That all the parties to this proceeding have been duly cited or have waived the issuance and service of a citation herein and
consented to the entry of a decree or order in the following manner and form:
a. By service of a copy of the citation issued herein upon the following persons in the manner prescribed by SCPA 307(1), as
more fully appears by the proof of service thereof, made in the manner and form by law and led on
____________ , 20 ___________.
Name Address Date of Service
__________________________________ __________________________________ _________________________________
__________________________________ __________________________________ _________________________________
b. By service pursuant to an order made herein on ____________ ,20 ______________________ , under SCPA307(2), as
more fully appears by the proof of service thereof, made in the manner prescribed by law and led herein on
__________ ,20 ______ .
Name Address Date of Service
__________________________________ __________________________________ _________________________________
__________________________________ __________________________________ _________________________________
(Parties who waive or consent)
c. By duly executed waivers of the issuance and service of the citation herein and a consent to the entry of a decree or order
and led herein on
___________________________________________ ,20 ______________________ ,by:
Name Address Date of Service
__________________________________ __________________________________ _________________________________
__________________________________ __________________________________ _________________________________
3. That no notice of appearance has been led herein, except by _________________________________________________
4. That all of the persons named above are of full age and are of sound mind, excepting those herein before stated to be
otherwise, and comprise all the parties, as deponent verily believes, who have any interest in this proceeding.
_________________________________
Signature
Sworn to before me this __________________________________
day of _____________________________________ ,20 ________
______________________________________________________
Notary Public
Commission Expires: (Afx Stamp and Seal)
N.B. Where a person cited is an infant, incarcerated, a mentally ill person, a mentally retarded person, a developmentally disabled
person, an alcohol abuser or for any cause is mentally incapable of adequately protecting his/her rights, it must so appear in the
foregoing afdavit. The age of the infant also must be stated.
A-7
Page 16 of 18
SURROGATE’S COURT OF THE STATE OF NEW YORK COUNTY OF
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ADMINISTRATION PROCEEDING WAIVER OF CITATION,
Estate of RENUNCIATION AND CONSENT TO
APPOINTMENT OF ADMINISTRATOR
(INDIVIDUAL)
a/k/a
Deceased. File No. ______________________________________________
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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 right to Letters of Administration of the above captioned estate and consents
that
[ ] Letters of Administration
[ ] Letters of Administration with Limitations
[ ] Limited Letters of Administration
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 specically release any claim I might have under any bond that may be led
[ ] 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
_______________________________________ ,20 ________ , before me personally appeared____________________________
__________________________________________ to me known and known to me to be the person described in and who executed the
foregoing waiver and consent and each duly acknowledged the execution thereof.
__________________________________________
Name of Attorney
__________________________________________
__________________________________________ __________________________________________
Notary Public Address
Commission Expires:
(Afx Stamp or Seal) __________________________________________
Telephone Number
A-8
Page 17 of 18
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
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ADMINISTRATION PROCEEDING WAIVER OF CITATION AND
Estate of CONSENT TO APPOINTMENT
OF ADMINISTRATOR
(CORPORATION)
a/k/a
Deceased. File No. ______________________________________________
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The undersigned corporation, a creditor of the above-named decedent, hereby voluntarily appears in the Surrogate’s
Court of
___________________________________________________ County, New York, and waives the issuance and service of
a citation in this matter and consents that Letters of Administration be issued to
___________________________________________
or any other person or persons entitled there to without any notice whatsoever to the undersigned,without furnishing a bond or other
security for the faithful performance of the duties of that ofce and specically releasing any claim it might have under any bond that
may be furnished.
Dated:
____________________________________ ,20 ________ _______________________________________________
(Name of Corporation)
By: _______________________________________
(Signature of Ofcer)
__________________________________________
(Type Name and Title)
STATE OF NEW YORK
COUNTY OF
__________________________________________ ss.:
On
_______________________________________ ,20 ________ , before me personally came
___________________________________________________________________________________________________________
to me known, who being duly sworn did say that: he resides at
_________________________________________________________
_________________________________________________________ ; he is a __________________________________________
______________________________________________________________ of ___________________________________________
______________________________________________________ ,the corporation described in and which executed the foregoing
waiver and consent; and that he signed the same thereto by order of the board of directors of the corporation.
__________________________________________
Name of Attorney
__________________________________________
__________________________________________ __________________________________________
Notary Public Address
Commission Expires:
(Afx Stamp or Seal) __________________________________________
Telephone Number
A-9
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Page 18 of 18
SURROGATE’S COURT OF THE STATE OF NEW YORK Note: File proof of Service at least 3 days before
COUNTY OF return date. State clearly date, time and place of service
----------------------------------------------------------------------X and name of person served (Uniform Rule 207.7(c)).
ADMINISTRATION PROCEEDING
Estate of AFFIDAVIT OF SERVICE
OF CITATION (Adult)
a/k/a
Deceased. File No. ________________________________________
---------------------------------------------------------------------------X
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 person-
ally 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 _____________________________________________
___________________________________________________________________________________________________________
On
__________________________________________________ , description, viz: sex _______________ , color of skin __________,
color of hair
___________________________________________ , approximate age ___________ , weight _______ , height ______,
at
________o’clock ___ m. on the _______ day of ____________ , 20 ___ ,at _____________________________________________
___________________________________________________________________________________________________________
On
__________________________________________________ , description, viz: sex _______________ , color of skin __________,
color of hair
___________________________________________ , approximate age ___________ , weight _______ , height ______,
at
________o’clock ___ m. on the _______ day of ____________ , 20 ___ ,at _____________________________________________
___________________________________________________________________________________________________________
That none of the aforesaid persons is in the Military Service as dened by the Act of Congress known as the “Soldiers’ and Sailors’ Civil
Relief Act of 1940” and in the New York “Soldiers’ and Sailors’ Civil Relief Act.
__________________________________________
Sworn to before me this __________________________________
day of _____________________________________ ,20 ________
______________________________________________________
Notary Public
Commission Expires: (Afx Stamp and Seal)
A-10