Fill and Sign the Fillable Online Confirmation of Earnings Coe Form

1. I am interested in this matter as. 2. Presumed decedent information: Domicile: 3. This petition is being filed not less than 63 days nor more than 7 years after the accident/disaster. 4. The presumed decedent apparently died as result of an accident or a disaster which occurred on or about and , if known, a. at , within this county. b. upon or within the Great Lakes or their connecting waters, at a location adjacent to this county. c. at a location outside of Michigan or its adjoining waters but the presumed decedent was domiciled in this county at the time of death. 5. The facts and circumstances concerning the accident or disaster are as follows: 6. The reasons I believe the presumed decedent died in the accident or disaster are as follows: In the matter of , presumed decedent PC 549 (9/05) PETITION TO ESTABLISH DEATH OF ACCIDENT OR DISASTER VICTIM JIS CODE: PED Approved, SCAO FILE NO. PETITION TO ESTABLISH DEATH OF ACCIDENT OR DISASTER VICTIM STATE OF MICHIGAN PROBATE COURTCOUNTY OF (PLEASE SEE OTHER SIDE) Do not write below this line - For court use only MCL 700.1207(e), (f), MCL 700.1208 State County Date Location City/Township/Village Date of birth Time Name of foreign country if citizen of foreign country Last four digits of SSN XXX-XX- is unidentifiable. 7. The body of the presumed deced ent has disappeared. 8. The name, age, and relationship to the presumed decedent and the address of each person known or believed to be an heir of the presumed decedent are as follows: 9. Of the above heirs, the following are under legal disability: I REQUEST that the court establish the location of the accident or disaster, the cause, and date of the presumed decedent's death, and, if possible, the time of death. I declare under the penalties of perjury that this petition has been examined by me and that its contents are true to the best of my information, knowledge, and belief. NAME DISABILITY NAME AGE RELATIONSHIP RESIDENCE REPRESENTED BY: (name, address, capacity) Attorney signature Address City, state, zip Attorney name (type or print) Telephone no. Date Petitioner signature Address City, state, zip Petitioner name (type or print) Telephone no. Bar no.