For Office Use Only
Filing Fee Paid $ _____________________
______________________
____________ Certs: _________________
Bond, Fee: _____________
Receipt No: ________ No:______________
- 1 -
DO NOT LEAVE ANY ITEMS BLANK
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
______________________________________________X
LETTERS OF ADMINISTRATION d.b.n.
ESTATE OF
a/k/a
Deceased.
______________________________________________X PETITION FOR
LETTERS OF ADMINISTRATION d.b.n.
SCPA 1007
[ ] Letters of Administration d.b.n.
[ ] Letters of Administration d.b.n. with
Limitations
[ ] Limited Letters of Administration d.b.n.
File No.______________________________
TO THE SURROGATE’S COURT, COUNTY OF __________________________
It is respectfully alleged:
1. (a) The name, citizenship, domicile (or, in the case of a blank or trust company, its principal office)
and
interest in this proceeding of the petitioner(s) is/are as follows:
Name: __________________________________________________________________________________________
________________________________________________________________________________________________
Domicile or Principal Office: (Street and Number) (City, Village or Town)
_______________________________________________________________________________________
(County) (State) (Zip Code)
(Telephone Number)
Mailing Address: __________________________________________________________________________________________
(If different from domicile)
Citizenship (Check one): [ ] U.S.A. [ ] Other (specify)
Name: _________________________________________________________________________________________________
(Street and Number)
(City, Village or Town)
________________________________________________________________________________________________ _______
(County) (State) (Zip Code)
(Telephone Number)
Domicile or Principal Office: _________________________________________________________________________
Mailing Address: ___________________________________________________________________________
(If different from domicile)
Citizenship (Check one): [ ] U.S.A. [ ] Other (specify)
Interest (s) of Petitioner (s): [Check one]
[ ] Distributee of decedent (state relationship)
[ ] Other [Specify]
1. (b) Is the proposed
Administrator d.b.n. an
attorney? Yes [ ] No [ ]
[NOTE: If yes, submit statement pursuant to 22 NYCRR 207.16(e); see also 207.52]
2. Letters of Administration of the above-named decedent were issued by this court on
________________, to _______________________, who on ______________
- 2 -
[ ] died [ ] resigned [ ] was removed.
ADM/DBN-1 (7/98)
[Note: For paragraphs 3a through c: Do not include any assets that are jointly held, held in trust for another, or
have a named beneficiary.]
3. (a) The estimated gross value of unadministered personal property passing by intestacy is less than
$ _________________.
(b) The estimated gross value of the decedent’s unadministered real property, in this state, which is
[ ] improved [ ] unimproved, passing intestacy is less then
$ _________________.
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) (a), 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 sufficient to cover the
probable amount to be recovered therein: (Write “NONE” or state briefly the cause of action and the
person against who 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 5.
See EPTL 5-4.4.
4. The decedent left surviving the following who would inherit his/her estate pursuant to EPTL 4-1.1
and
4-1.2:
a. [ ] Spouse (husband/wife). [ ] Divorced
[Attach copy of Divorce Decree]
b. [ ] Child or children or descendants of predeceased child or children, [ Must
include marital,
non-marital, and adopted].
c. [ ] Any issue of the decedent adopted by persons related to the decedent (DRL
Section 117).
d. [ ] Mother/Father.
e. [ ] Sisters and brothers , either of whole or half blood, and issue of predeceased
sisters and brothers.
f. [ ] Grandmother/Grandfather.
g. [ ] Aunts or uncles, and children of predeceased aunts and uncles (first cousins).
h. [ ] First cousins once removed (children of first cousins).
- 3 -
[Information is required only as to those classes of relatives who would take the property of decedent pursuant to EPTL
4-1.1. State “numbers” of survivors in each class. Insert “NO” in all prior classes. Insert “X” in all subsequent classes].
- 4 -
5. The decedent left surviving the following distributees, or other necessary parties, whose names, degrees
of relationship, domiciles, post office addresses 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 (5) is not sufficient. See Uniform Rules 207.16 (b). If any person listed in paragraph (5) is a nonmarital
person, or descended from a nonmarital person, attach a copy of the order of filiation or Schedule A. If any
person listed in paragraph (5) was adopted by any persons related by blood or marriage to decedent or
descended from such persons, attach Schedule B.]
5a. The following are of full age and under no disability: [If nonmarital or adopted-out person, so indicate by
attaching Schedule A and/or B. If any of the distributees have died subsequent to the death of the decedent, give the
name and title of the legal representative appointed for such person (s), his or her address and the court that issued such
letters. If any distributee who has died, subsequent to the death of the decedent, has no legal representative, then enter
the name, relationship, domicile address and citizenship of that deceased person (s) distributee (s).]
Name
Relationship
Domicile and
Citizenship
Mailing address
5b. The following are infants and/or persons under disability: [Attach applicable Schedule A, B, C and/or D]
Name
Relationship
Domicile and
Citizenship
Mailing address
- 6 -
6. There are no persons interested in this proceeding other than those herein mentioned.
7. There are no outstanding debts or funeral expenses, except: [Write “NONE” or state same]
WHEREFORE, your petitioner (s) respectfully pray (s) 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 5 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 d.b.n. 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 foregoing Letters be limited
with respect to the prosecution 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)
3. _______________________________________
(Name of Corporate Petitioner)
_______________________________________
(Signature of Officer)
_______________________________________
(Print Name and Title of Officer)
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
_________________________________________ X
LETTERS OF ADMINISTRATION d.b.n.
ESTATE OF
a/k/a
Deceased.
X SCHEDULE A
NONMARITAL PERSONS
(PERSONS BORN OUT OF WEDLOCK)
File No. ____________________________
- 8 -
[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 certificate
contain the father’s
name? Yes
[ ] No
[ ]
If yes, attach a copy of birth certificate.
Has an order of filiation establishing paternity been entered?
Yes [ ] No [ ] If yes, attach a copy of order.
Did the nonmarital
person live with his or
her father?
Yes [ ]
No [ ]
If yes, give dates and place of residence: __________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
-5-
- 9 -
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
X
LETTERS OF ADMINISTRATION d.b.n.
ESTATE OF
a/k/a
Deceased.
X SCHEDULE B
ISSUE OF THE DECEDENT
WHO WERE THE SUBJECT OF AN ADOPTION
File No:________________________________
Name of child: _____________________________________________________________________________
Relationship to decedent prior to adoption: _______________________________________________________
Date of adoption: ___________________________________________________________________________
Was this a ste-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:
[ ] grandparents (s)
[ ] brother or sister
[ ] aunt or uncle
[ ] first cousin
[ ] nephew or niece
Name of the adoptive parent ________________________________________________________________________
-6-
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
X
LETTERS OF ADMINISTRATION d.b.n.
ESTATE OF
a/k/a
Deceased.
X SCHEDULE C
INFANTS
File No._______________________________
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 the 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 the infant have a
court-appointed
guardian? Yes
[ ]
No [ ]
If yes, name and address of guardian: ___________________________________________________
__________________________________________________________________________________
-7-
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
X
LETTERS OF ADMINISTRATION d.b.n.
ESTATE OF
a/k/a
Deceased.
X SCHEDULE D
PERSONS UNDER DISABILITY
OTHER THAN INFANTS
File No. _________________________
[Use additional sheets if needed]
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
fiduciary? 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. Whereabouts unknown/Unknowns [persons whose addresses or names are unknown to petitioner; if known, give
name and relationship to decedent]: ____
____
____
____
____
_______ ____
____
____
____
-8-
COMBINED VERIFICATION, OATH & DESIGNATION
[For use when petitioner is to be appointed administrator d.b.n.]
STATE OF__________________________)
COUNTY OF ________________________) ss:
The undersigned, the petitioner named in the foregoing petition, being duly sworn, says:
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 therein stated to be alleged upon information and
belief, and as to those matters I believe it to be true.
2. OATH OF ADMINISTRATOR d.b.n.: I am over eighteen (18) years of age and a citizen of the United
States; I will well, faithfully and honestly discharge the duties of the administrator d.b.n.. I am not ineligible to receive letters .
3. DESIGNATION OF CLERK FOR SERVICE OF PROCESS: I do hereby designate the Clerk of the
Surrogate’s Court of County, and his or her successor in office, 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 within the State of New York after due diligence used.
My domicile is ______________________________________________________________________________
(Street
Address)
(City/Town/Villa
ge)
(State)
(Zip
Code)
______________________________________________
(Signature of Petitioner)
_____________________________________________
(Print Name)
On , , 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:
(Affix Notary Stamp or Seal)
Signature of Attorney: ______________________________________________________________________________
Print Name: ______________________________________________________________________________________
Firm Name: Tel. No.: ____________________________
Address of Attorney: _______________________________________________________________________________
-9-
COMBINED CORPORATE VERIFICATION, CONSENT AND DESIGNATION
[For use when a petitioner to be appointed is a bank or trust company]
STATE OF __________________________)
COUNTY OF_________________________) ss:
The undersigned, a of
(Title)
(Name of Bank or Trust Company)
a corporation duly qualified to act in a fiduciary capacity without further security, being duly sworn, says:
1. VERIFICATION: I have read the foregoing petitioner subscribed by me and know the contents
thereof, and the same is true of my own knowledge, except as to the matters therein stated to be alleged upon information
and belief, and as to those matters I believe it to be true.
2. CONSENT: I consent to accept the appointment as Administrator d.b.n. of the decedent described in
the foregoing petition and consent to act as such fiduciary.
3. DESIGNATION OF CLERK FOR SERVICE OF PROCESS: I do hereby designate the Clerk of the
Surrogate’s Court of County, and his or her successor in office, 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 within the State of New York after due diligence used.
_______________________________________
(Name of Corporate Petitioner)
_______________________________________
(Signature of Officer)
_______________________________________
(Print Name and Title of Officer)
On the __________________________ , __________, before me personally came _______________________
to me known, who duly sworn to the foregoing instrument and who did say that he/she resides at ___________________
______________________ and that he/she is a ________________________________________________________ of
_______________________________the corporation/national banking association described in and which executed such
instrument, and the he/she signed his/her name thereto by order of the Board of Directors of the corporation.
_____________________________________
Notary Public
Commission Expires:
(Affix Notary Stamp or Seal)
Signature of Attorney: ______________________________________________________________________________
Print Name: ______________________________________________________________________________________
Firm Name: Tel. No.:_____________________________
Address of Attorney: _______________________________________________________________________________
-10-
LETTERS OF ADMINISTRATION d.b.n. 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 filed by , who is
domiciled at ______________________________________________________________________________________
YOU ARE HEREBY CITED TO SHOW CAUSE before the Surrogate’s Court, _____________________ County,
at ________________________________________ , New York, on __________________________________,_______,
at ________________ o’clock in the ________________ noon of that day, why a decree should not be made in the estate
of ______________________________________________________________________________________________
lately domiciled at _________________________________________________________________________________
granting administration d.b.n. and directing that
[ ] Letters of Administration d.b.n. issue to:
___________________________________________________
[ ] Letters of Administration d.b.n. with Limitations issue to:
______________________________________
[ ] Limited Letters of Administration d.b.n. issue to :
____________________________________________
(State any further relief requested)
HON. ___________________________________________
Dated, Attested and Sealed, Surrogate
_________________________________ , _______
____________________________________________
(Seal)
Chief
Clerk
________________________________________________________________________________________________
Attorney For Petitioner
Telephone
Number
________________________________________________________________________________________________
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 appear for you.]
ADM/DBN-2 (7/98)
-11-
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
_______________________________________________ X
LETTERS OF ADMINISTRATION d.b.n.
ESTATE OF WAIVER OF CITATION,
RENUNCIATION AND CONSENT
TO APPOINTMENT OF ADMINISTRATION d.b.n.
(INDIVIDUAL)
File No. _______________________
a/k/a
Decreased.
_______________________________________________ X
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 rights to Letters of Administration d.b.n. of the above captioned estate and
consents that
[ ] Letters of Administration d.b.n.
[ ] Letters of Administration d.b.n. with Limitations
[ ] Limited Letters of Administration d.b.n.
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 specifically releases any claim the undersigned might
have
under any bond that may be filed.
[ ] 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 __________________________________________, _____________________, before me personally came
_________________________________________________________________________________________________
to me known and 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:
(Affix Notary Stamp or Seal)
Name of Attorney: ________________________________________________ Tel. No.: _________________________
Address of Attorney:________________________________________________________________________________
ADM/DBN-3 (10/04)
-12-
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
________________________________________________ X
LETTERS OF ADMINISTRATION d.b.n.
ESTATE OF
a/k/a
Deceased.
_______________________________________________ X CONSENT TO APPOINTMENT OF
ADMINISTRATOR d.b.n.
(CORPORATION)
File No. _______________________
The undersigned corporation voluntarily appears in the Surrogate’s Court of _______________________ County, New
York, and consents that
[ ] Letters of Administration d.b.n.
[ ] Letters of Administration d.b.n. with Limitations
[ ] Limited Letters of Administration d.b.n.
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 specifically releases any claim the undersigned might
have under any bond that may be filed.
[ ] that a bond in the amount of $ _________________________________ be posted.
_________ _________________________________________
Date Name of Corporation
By: _________________________________________
(Signature of Officer)
_________________________________________
(Type Name and Title)
STATE OF NEW YORK
COUNTY OF ________________________ss.:
On __________________________________________ , _____________________, before me personally came
_________________________________________________________________________________________________
to me known, who being duly sworn did say that: (s)he resides at ____________________________________________
__________________________________________ of ____________________________________________________
the corporation described in and which executed the foregoing consent; and that (s)he signed the same thereto by order
of the board of directors of the above corporation.
___________________________________
Notary Public
Commission Expires:
(Affix Notary Stamp or Seal)
Name of Attorney: ________________________________________________ Tel. No.: _________________________
Address of Attorney:________________________________________________________________________________
ADM/DBN-4 (10/04)
-13-
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
_______________________________________________X
LETTERS OF ADMINISTRATION d.b.n.
ESTATE OF NOTICE OF APPLICATION FOR
LETTERS OF ADMINISTRATION d.b.n.
(SCPA 1005)
File No. _________________________
a/k/a
Deceased.
_______________________________________________X
Notice is Hereby Given That:
1. An application for Letters of Administration d.b.n. upon the estate of the above-named decedent, has been
made by________________________________________________________, petitioner, whose post office 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 d.b.n. to
________________________________________________________________________________________________
4. The name and post office 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, or have waived citation or have appeared in this
proceeding:
Name of Distributee
Domicile and Post
Office Address
_____________________________________________
____________________________________________
_____________________________________________
____________________________________________
(b). Other Distributees:
Name of Distributee
Domicile and Post
Office Address
_____________________________________________
____________________________________________
_____________________________________________
____________________________________________
[IF MORE SPACE IS NEEDED ADD RIDER]
5. The undersigned does not know of any other distributees of the said decedent.
6. Letters of Administration d.b.n. will issue on or after _____________________ , ___________
Dated ___________________, ______________
___________________________________________
Signature of Petitioner or Attorney
___________________________________________
Print Name
___________________________________________
Address
Name of Attorney: ________________________________________________ Tel. No.: _________________________
Address of Attorney: _______________________________________________________________________________
ADM/DBN – 5 (7/98)
-14-
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
X
LETTERS OF ADMINISTRATION d.b.n. AFFIDAVIT OF MAILING
ESTATE OF NOTICE OF APPLICATION FOR
LETTERS OF ADMINISTRATION d.b.n.
(SCPA 1005)
File No. ______________________
a/k/a
Deceased.
_______________________________________________ X
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 __________________, ________,
deponent mailed a copy of the foregoing Notice of Application for Letters of Administration d.b.n. , contained in a securely
closed postpaid wrapper, directed to each of the persons named in paragraph 4 (b), respectively, as follows:
whose post office address is __________________________________________________________________________
whose post office address is __________________________________________________________________________
whose post office address is __________________________________________________________________________
whose post office address is __________________________________________________________________________
whose post office address is __________________________________________________________________________
whose post office address is __________________________________________________________________________
whose post office address is __________________________________________________________________________
whose post office address is __________________________________________________________________________
by depositing the document in a letters box or other official depository under the exclusive care and custody of the United
States Post Office located at:
_________________________________________________________________________________________________
________________________________
Signature
Sworn to before me this __________
day of ________________, _______
_____________________________
Notary Public
Commission Expires:
(Affix Notary Stamp or Seal)
ADM/DBN-6 (7/98)
-15-
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
_______________________________________________ X
LETTERS OF ADMINISTRATION d.b.n.
ESTATE OF NOTICE TO THE CONSUL
GENERAL
File No. ___________________
a/k/a
Deceased.
_______________________________________________ X
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 _______________________________ , ________ , 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 Number
STATE OF NEW YORK
COUNTY OF ________________________ss.:
__________________________________________, being duly sworn, says:
That he/she resides at __________________________________________________________ , New York; that
on the _______________________________________________ , _______________, he/she served a copy of the
above
NOTICE on the Counsel General of ______________________________________at ___________________________ ,
New York City, by mailing same to the office of the aforesaid Consul.
Sworn to before me this __________
day of ________________, _______
_____________________________
Notary Public
Commission Expires:
(Affix notary Stamp or Seal)
ADM/DBN-7
-16-
SURROGATE’S COURT OF THE STATE OF NEW YORK
COUNTY OF
_______________________________________________ X
LETTERS OF ADMINISTRATION d.b.n.
ESTATE OF
a/k/a
Deceased.
_______________________________________________ X Note: File Proof of Service at least
3 days before return date. State
clearly date, time and place of
service and name of person served
(Uniform Rule 207.7 (c)).
AFFIDAVIT OF SERVICE
OF CITATION (Adult)
File No. ____________________
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 personally 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 defined 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:
(Affix Notary Stamp or Seal)
ADM/DBN-8 (7/98) -17-
