Fill and Sign the Article 25 Small Estates28a 25 1 Collection of Property by Form

Minus Distributions To Heirs As Shown In Pa rt IV ............. .. ................................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 1 - 0 3 . S . G r e d n U t r u o C e h T y B d e v o r p p A e c n a w o l l A l a s u o p S s u n i M To tal Pe rsonal Pro perty Rece ived As Shown in Part II ....... ..................................................................... TO TAL REC EIPT S DAT E RE CE IVED RE CE IV ED FRO M DESCR IPTIO N VALUE BAL ANCE AT TH E END (Thi s will alwa ys be zero) 2. $ _ N ame O f D ecede nt $ STA TE OF NOR TH CAROLI NA File N o. (Ov er) AFFIDAVIT OF C O LLEC TIO N, D ISB URSEMEN T A ND D IST RIB UTIO N In T he G en e ra l C ou rt Of J u stic e S up e rio r C ou rt D iv is io n B efore T he C le rk Cou nty G. S. 28A -25- 3(a)(2) I, t he und ersigne d collecto r by a ffidav it, being first duly sworn, say that the fo llowing is a co mplete a nd a ccu rate acco unt o f my re ce ipts, disbursements, and d istributions as co llecto r by a ffidav it of the pers onal pro perty o f this e state. IN TH E MA TTER O F TH E ESTATE OF Exte n d in g T o A cc o u n tin g P erio d F ro m A O C- E-204, Rev. 1/ 12 © 2012 A dm ini str ativ e Of fice of the Cour ts PART I. SU MMARY 1. $ 4. $ _ $ 5. PART II. PERSO NAL PROPE RTY R EC EIVE D Minus Disbursements (Debts o r Expense) As Shown In Pa rt III ............................................................. 3 . _$ AOC-E-204, Side Two, Rev. 1/12 © 2012 Administrative Office of the Courts TOTAL BALANCE $ Deputy CSC A ssistant CSC Clerk O f S uperior C ourt SWORN/A FFIRMED AND SUBSCRIBED T O BEFORE ME Date Notary SEAL Si gnature Date Co mmission Expires County W here Notarized Signature O f A ffi ant 2 TOTAL DIS BURSEMENTS $ DATE PAID TO FOR AMOUNT PART III. DISBURSEMENT (DEB TS O R EXPEN SE) HEIRS AMOUNT $ P ART IV. BAL ANCE DI STRIBUTED T O HEIRS $ Signature O f A ffi ant 1 Deputy CSC A ssistant CSC Clerk O f S uperior C ourt SWORN/A FFIRMED AND SUBSCRIBED T O BEFO RE ME Signature Date Notary Date Commi ssion Expires SEAL County W here Notarized