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For Ofce 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 Certicate 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 Certicate must be led with this proceeding. If the decedent’s domicile is different from that shown on the death
certicate, 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)