Fill and Sign the Estate Assets and Income Form

NHJB-2143-P (10/01/2006) Page 1 of 2 (formerly AOC 203-003) THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Estate of STATEMENT OF VOLUNTARY ADMINISTRATION ESTATE ASSETS AND INCOME (List personal estate assets as reported on Voluntary Administration Affidavit and income earned on estate assets.) A. $ B. $ C. $ 1. TOTAL ESTATE ASSETS AND INCOME $ BILLS PAID FROM ESTATE ASSETS AND INCOME (List only expenses paid from estate assets reported on Voluntary Administration Affidavit and income earned on estate assets.) A. Funeral expenses and last sickness $ B. Other bills paid such as debts, taxes and estate expenses $ (List each specific bill and amount below.) 2. TOTAL BILLS PAID FROM ESTATE ASSETS AND INCOME EARNED $ 3. BALANCE IN HAND TO BE DISTRIBUTED TO LEGATEES OR HEIRS ONLY AFTER RECEIVING THE COURT'S APPROVAL $ I, , Voluntary Administrator of the estate, state the above is a true and accurate statement of my administration. Date Voluntary Administrator Signature State of , County of This instrument was acknowledged before me on by My Commission Expires Affix Seal, if any Signature of Notarial Officer / Title Case Name: Estate of Case Number: STATEMENT OF VOLUNTARY ADMINISTRATION NHJB-2143-P (10/01/2006) Page 2 of 2 (formerly AOC 203-003) ORDER This statement is approved. This statement is disapproved. Date Judge of Probate