GPCSF 9 [i] Eff. July 2017
PETITION FOR ORDER DECLARING
NO ADMINISTRATION NECESSARY
INSTRUCTIONS
I. Specific Instructions
1. This form is to be used when filing a Petition for an Order Dec laring No Administration
Necessary, pursuant to O.C.G.A. § 53-2-40 et seq., and should o nly be used when the
Decedent died intestate (without a Will).
2. Unanimous consent of the heirs at law to the agreed upon divisi on is required according
to O.C.G.A. § 53-2-40 (b).
3. Signatures of heirs who acknowledge service must be sworn to be fore a notary public
or the Clerk of any Probate Court of this State. It is not nec essary that all
acknowledgments appear on the sa me page. An attorney at law may acknowledge
service on behalf of an heir; however, the attorney must certify that he or she currently
represents that heir w ith regard to the pending matter and, in order to comply with
O.C.G.A. § 53-11-6, the attorney's signature must be sworn to a s provided above. With
regard to a power of attorney, th e attorney-in-fact may acknowledge service on behalf
of the grantor of the power, provided that the power of attorne y grants such authority,
the signature of the attorney-in- fact is attested, a copy of the power of attorney is
attached, and the a ttorney-in-fact certif ies that the copy is a true copy and is still in
effect. It is not necessary that all acknowledgments appear on the same page.
4. O.C.G.A. § 53-11-2 provides that a party to a probate proceedin g who is not sui juris
must be represented by a guardian provided that the Court may a ppoint a guardian ad
litem or determine that the natural guardian, guardian, conservator, or testamentary
guardian has no conflict and may serve. Should a guardian ad l item be necessary
because a party is not sui juris, use Supplement 1.
5. O.C.G.A. § 53-2-40 (c) provides that the personal representative of a deceased heir is
authorized to agree to t he division of property.
6. A signed original agreement se tting out the heirs’ agreed upon distribution of the estate
must be attached to the Petition. The legal description includ ed in the agreement must
sufficiently identify the prope rty in order to pass good title.
7. Paragraph 4 requires sufficient factual information for the Court to conclude that those
listed in Paragraph 3 include each and every heir of the Decede nt and that there are not
additional heirs of the same or closer degree according to O.C. G.A. § 53-2-1. These
facts must allow the Court to rule out the possibility that the re may be other heirs of
the same or closer degree who have not been listed. Provide the date of death of any
deceased heirs and the name of the deceased heir’s Personal Rep resentative if
applicable. The Personal Repres entative of a deceased heir is authorized to consent on
behalf of that heir. O.C.G.A. § 53-6-30. [NOTE: If you are un certain how to determine
the heirs of a Decedent, refer to the “Heirs Determination Work sheet” available from
the Probate Court or at www.gaprobate.gov.] Examples of such s tatement would be:
(a) “Decedent was or was not married at the time of his death and had no children born,
GPCSF 9 [ii] Eff. July 2017
adopted, living or deceased, other than listed herein”; (b) “Decedent had no other
siblings half or whole other than those listed herein”; (c) “the Decedent’s brother who
died previously had no other children born, adopted, living or deceased, other than
listed herein.”
8. Use Supplement 2 if the Court de termines it is appropriate to appoint a special process
server.
9. Use Supplement 3 when an addition al certificate of service is necessary.
10. Exhibits should be labeled at the bottom of each exhibit as Exh ibit “A,” Exhibit “B,”
etc. in consecutive order. The corresponding letter of each sai d exhibit should be
inserted into the appropriate place in the form.
11. According to Uniform Probate Court Rule 5.6 (A), unless the Cou rt specifically
assumes the responsibility, it is the responsibility of the mov ing party to prepare the
proper citation and deliver it pr operly so it can be served according to law. All pages
after the Notice regarding Unif orm Probate Court Rule 5.6 (A) a re to be completed by
the moving party, unless otherw ise directed by the Court.
II. General Instructions
General instructions applicable to all Georgia Probate Court St andard Forms are
available in each Probate Cour t or at www.gaprobate.gov, labele d GPCSF 1.
GPCSF 9 [1] Eff. July 2017
IN THE PROBATE CO
URT OF _______________________ COUNTY
STATE OF GEORGIA
IN RE: ESTATE OF ) )
___________________________________ , ) ESTATE NO. ____________
DECEASED )
PETITION FOR ORDER DECLARING NO ADMINISTRATION NECESSARY
The Petition of _______________________________________________ ____________
[Full name(s) of Petitioner(s)] First Middle Last
whose physical address(es) is/are _____________________________ _____________________,
Street City County State Zip Code
and mailing address(es) is/are ________________________________ _____________________,
Street City County State Zip Code
shows to the Court the following: 1.
_______________________________________________________________ ______,
[Full name of Decedent] First Middle Last
whose place of domic ile was ___________________________________ _________________,
Street City County State Zip Code
died intestate (without a will) on _______________, 20 _____, o wning property in this state.
2.
The above named Decedent died without a valid Last Will and Te stament.
3.
Listed below are all of the Decedent's heirs at law, with age or majority status, address and
relationship to the Decedent set opposite the name of each:
Name Age (or over 18) Address Relationship ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
GPCSF 9 [2] Eff. July 2017
4.
Required : [Provide sufficient factual information to enable the Court to conclude that all
of the heirs of the Decedent are in cluded and that there are no heirs of the same or closer degree
according to O.C.G.A. § 53-2-1. Provide the na mes of any deceased heirs, the name and address
of his or her Personal Representative, if any , and include the date of death for each. [See
instructions for further clarification.] Also, st ate here all pertinent facts that may govern the
method of giving notice to any party and that may determine wh ether or not a guardian ad litem
should be appointed for any party . If any heirs listed above are cousins, grandchildren, nephews
or nieces of the Decedent, indi cate the deceased ancestor through whom they are related to the
Decedent.]
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
5.
The Decedent owned the following described personal property in this state [include
identifying account numbers, serial numbers, etc., where applicable]:
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 6.
The Decedent owned the following described real property in thi s state [insert complete
legal description and street address, if any] :
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
GPCSF 9 [3] Eff. July 2017
7.
As to the estate of said Decedent: [Initial all that apply]
___________ (a) The estate of Decedent owes no debts.
___________ (b) The estate of Decedent owes no debts, other than an outstanding
security deed held by (complete name(s) and address(es) including
zip codes must be provided for each creditor so listed)________ __
___________________________________________, who must be
properly served in this matter unl ess such holder has consented in
writing below to the petition.
___________ (c) The estate of Decedent owes no debts, other tha n to such creditor(s)
as have consented in writing to the petition, as shown on the c onsent
below.
___________ (d) The estate of Decedent owes no debts, other th an (complete name(s)
and address(es) including zip codes must be provided for each
creditor so listed) those listed immediately below who have not
consented in writi ng and must be serve d as provided by law:
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
8.
All the heirs have amicably agreed upon a division of the esta te among themselves as
shown by the written agreement attached hereto containing origi nal signatures of all heirs, attested
to by a notary public or Pr obate Court Clerk.
9.
To the knowledge of the Petitioner, no other proceedings with respect to this estate are
pending, or have been completed, in any other Probate Court in this state.
GPCSF 9 [4] Eff. July 2017
WHEREFORE, Petitioner prays that this Court issue and serve any
notice required by law in such
matters, and that after ascertaini ng the legal sufficiency for granting this Petition, this Court grant
an Order that no administration i s necessary in this estate, all as provided by law.
____________________________________
Signature of Petitioner ____________________________________
Printed Name ____________________________________ ____________________________________ Mailing Address ____________________________________
Telephone Number Signature of Attorney ______________________________________________________
Printed Name of Attorney ______________________________________ ________________
Address ______________________________________________________
______________________________________________________
Telephone Number __________________ State Bar #______________ __________
GPCSF 9 [5] Eff. July 2017
VERIFICATION
GEORGIA, ___________________ COUNTY
Personally appeared before me the undersigned Petitioner(s) who , after being duly sworn,
state(s) that the facts set fort h in the foregoing Petition for Order Declaring No Administration
Necessary (and the attached Exhi bit(s)) are true and correct.
Sworn to and subscribed before me this
______ day of _______________, 2 0_____ ________ _____________________________
Signature of Petitioner
___________________________________ _____________________________________
NOTARY/CLERK OF PROBATE COUR T Printed Name of Petitioner
My Commission Expires ________________
GPCSF 9 [6] Eff. July 2017
IN THE PROBATE CO
URT OF _______________________ COUNTY
STATE OF GEORGIA
IN RE: ESTATE OF ) )
___________________________________ , ) ESTATE NO. ____________
DECEASED )
AGREEMENT AND
ACKNOWLEDGMENT OF SERVICE AND CONSENT
We, being all of the heirs of the above-named Decedent, hereby agree to the division of the
Decedent’s estate among ourselv es in the amounts and portions w hich would otherwise be
determined in accordance with the rules of inheritance when a D ecedent dies without a will, or if
different, as follows:
We hereby agree that the followi ng interests vest as set forth below:
_____________________________________________________________________________________
[Full Name of individual to receive interest]
_____________________________________________________________________________________
[Complete address including zip code of individual to receive interest]
_____________________________________________________________________________________
[Date of Birth or Majority Status] [Interest or percentage received pursuant to this Order]
--------------------------------------------------------------- ------------------------------------------ ------------
_____________________________________________________________________________________
[Full Name of individual to receive interest]
_____________________________________________________________________________________
[Complete address including zip code of individual to receive interest]
_____________________________________________________________________________________
[Date of Birth or Majority Status] [Interest or percentage received pursuant to this Order]
GPCSF 9 [7] Eff. July 2017
_____________________________________________________________________________________
[Full Name of individual to receive interest]
_____________________________________________________________________________________
[Complete address including
zip code of individual to receive interest]
_____________________________________________________________________________________
[Date of Birth or Majority Status] [Interest or percentage received pursuant to this Order]
--------------------------------------------------------------- ------------------------------------------ ------------
_____________________________________________________________________________________
[Full Name of individual to receive interest]
_____________________________________________________________________________________
[Complete address including zip code of individual to receive interest]
_____________________________________________________________________________________
[Date of Birth or Majority Status] [Interest or percentage received pursuant to this Order]
--------------------------------------------------------------- ------------------------------------------ ------------
Legal Description and Location of Real Property:
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
GPCSF 9 [8] Eff. July 2017
Each of the undersigned heirs or creditors (including any secur
ity deed holder) hereby
acknowledges due and legal servic e of the foregoing Petition, waives copies of same and all further
service and notice in this matter, and consents to this agreeme nt the terms of which shall be
included in the Final Order Declaring that No Administration is Necessary. For each individual
named put the appropriate letter to show the relationship to th e Decedent - Heir (H), or Creditor
(C).
Sworn to and subscribed before me this
______ day of _______________, 20_____ __________________ __________________
Signature of Interested Party
___________________________________ _____________________________________
NOTARY/CLERK OF PROBATE COURT Pr inted Name of Interested Party
My Commission Expires ________________
--------------------------------------------------------------- ------------------------------------------ ------------
Sworn to and subscribed before me this
______ day of _______________, 20_____ __________________ __________________
Signature of Interested Party
___________________________________ _____________________________________
NOTARY/CLERK OF PROBATE COURT Pr inted Name of Interested Party
My Commission Expires ________________
--------------------------------------------------------------- ------------------------------------------ ------------
Sworn to and subscribed before me this
______ day of _______________, 20_____ __________________ __________________
Signature of Interested Party
___________________________________ _____________________________________
NOTARY/CLERK OF PROBATE COURT Pr inted Name of Interested Party
My Commission Expires ________________
--------------------------------------------------------------- ------------------------------------------ ------------
Sworn to and subscribed before me this
______ day of _______________, 20_____ __________________ __________________
Signature of Interested Party
___________________________________ _____________________________________
NOTARY/CLERK OF PROBATE COURT Pr inted Name of Interested Party
My Commission Expires ________________
GPCSF 9 [9] Eff. July 2017
NOTICE
THE FOLLOWING PAGES ARE TO BE
COMPLETED BY THE PETITIONER (MOVING PARTY) UNLESS OTHERWISE DIRECTED BY THE COURT.
SEE PROBATE COURT RULE 5.6 (A).
GPCSF 9 [10] Eff. July 2017
IN THE PROBATE CO
URT OF _______________________ COUNTY
STATE OF GEORGIA
IN RE: ESTATE OF ) )
___________________________________ , ) ESTATE NO. ____________
DECEASED )
ORDER FOR SERVICE OF NOTICE
[Not Needed If All Creditors Have Consented]
The foregoing Petition for Order Declaring No Administration Ne cessary having been
filed, service is ordered as follows:
[Initial all that apply] ______ Notice together with a copy of the Petition shall be served pe rsonally, or by
registered or certified mail or statutory overnight delivery, a s requested by the Petitioner(s)
pursuant to O.C.G.A. § 53-11-3, at least ten (10) days before t he petition can be granted on the
following interested parties who reside in Georgia: [if mailed, must be with return receipt
requested, and restricted de livery to addressee only]
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
______ Notice together with a copy of the Petition shall be served by registered or certified
mail, return receipt requested, pursuant to O.C.G.A. § 53-11-4, upon the following nonresident
interested parties whose current residence addresses are known:
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
______ Notice shall be pub lished once a week for four (4) weeks in the legal organ of this
County, before _________________________ , 20____ , in order to serve by publication the
following interested parties whos e current residence addresses are unknown:
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
GPCSF 9 [11] Eff. July 2017
OR
Upon reading and considering the foregoing Petition for Order Declaring No
Administration Necessary, IT IS OR DERED that notice issue thereon as required by law, requiring
all non sui juris heirs by and through guardian ad litem and/or creditors who have not consented
to the Petition to show cause in writing filed in this Court on or before a day certain, if published,
or within ten (10) days of personal service, whichever is la ter, why the prayers of the Petitioner
should not be granted as prayed, and an Order granted that no a dministration is necessary in this
estate. Further Ordered that a ny security deed holder or other creditor who has not consented in
writing to the Petition and whose current address is known be s erved with a copy of the Petition,
this Order, and the following Notice, personally or by register ed or certified mail or statutory
overnight delivery, as requested by the Petitioner(s) pursuant to O.C.G.A. § 53-11-3, if a resident
of this state, or by registered o r certified mail, return receipt requested, if a nonresident with a
known current address. Any cred itor whose current address is not known must be served by
publishing the notice once a week for four (4) weeks.
SO ORDERED this _______ day of ________________, 20____.
_________________________ ____________
Judge of the Probate Court
GPCSF 9 [12] Eff. July 2017
IN THE PROBATE CO
URT OF _______________________ COUNTY
STATE OF GEORGIA
IN RE: ESTATE OF ) )
___________________________________ , ) ESTATE NO. ____________
DECEASED )
NOTICE
The Petition of _______________________________________________ __, for an Order
Declaring No Administration is N ecessary in the above-referenced estate having been duly filed,
[Strike any paragraph if not applicable]
TO: _______________________________________________________________ ________
[List here all interested parties having known addresses in Ge orgia to be served personally or by registered or certified
mail or statutory overnight delivery with restricted delivery to the addressee, if specifically requested by the Petitioner(s)]
This is to notify you who are re quired to be served personally, to file objection, if there is
any, to the Petition, in this Court on or before the tenth (10t h) day after the date you are personally
served or sign the return receipt.
TO: _______________ ______________________________ __________________________
[List here all interested parties having k nown addresses outside the continental U.S. to be served by registered or certified
mail or statutory overnight delivery with restricted delivery to the addressee, if specifically requested by the Petitioner(s)]
This is to notify you to file o bjection, if there is any, to the Petition, in this Court on or
before the thirtieth (30th) day after ____________, 20_____ (the date of the mailing of this Notice
to you by certified or registered mail, return receipt requeste d); provided, however, that if a return
receipt for such Notice is act ually received by the Court within such thirty (30) days, the deadline
for the filing of any objection shall be ten (10) days from the date of receipt shown on such return
receipt.
TO: _____________ __________________________________________________________
[List here all interested parties having k nown addresses in the continental U.S. to be served by registered or certified or
statutory overnight deliver y with restricted delivery to the addressee, if specifically requested by the Petitioner(s)]
This is to notify you to file obj ection, if there is any, to the Petition, in this Court on or
before the thirteenth (13th) day after _________________, 20_____ (the date of the mailing of
this Notice to you by certified or registered mail, return rece ipt requested); provided, however, that
if a return receipt for such N otice is actually received by the Court within such thirteen (13) days,
the deadline for the filing of any objection shall be ten (10) days from the date of receipt shown
on such return receipt.
BE NOTIFIED FURTHER: All objections to the Petition must be in writing, setting for th
the grounds of any such object ions. All objections should be s worn to before a notary public or
before a Probate Court Clerk, and filing fees must be tendered with your objections, unless you
qualify to file as an indigent party. Contact Probate Court personnel for the required amount of
filing fees. If any objections are filed, a hearing will be (h eld on ___________________, 20_____)
(scheduled at a later date). I f no objections are filed, the P etition may be granted without a hearing.
GPCSF 9 [13] Eff. July 2017
This __________ day of __________, 20__.
_________________________ ____________
Judge of the Probate Court
By: _________________________________
Clerk of the Probate Court
_________________________ ____________
_________________________ ____________
Address
_________________________ ____________
Telephone Number
GPCSF 9 [14] Eff. July 2017
IN THE PROBATE CO
URT OF _______________________ COUNTY
STATE OF GEORGIA
IN RE: ESTATE OF ) )
___________________________________ , ) ESTATE NO. ____________
DECEASED )
NOTICE
The Petition of _______________________________________________ __, for an Order
Declaring No Administr ation is Necessary in the above-referenced estate having been duly filed,
TO: ________________________________________________________________________
[List here all interested parties having unkn own addresses to be served by publication]
This is to notify you to file o bjection, if there is any, to the Petition, in this Court on or
before _______________________________ , 20_____ .
BE NOTIFIED FURTHER : All objections to the Petition must be in writing, setting fo rth
the grounds of any such object ions. All objections should be s worn to before a notary public or
before a Probate Court Clerk, and filing fees must be tendered with your objections, unless you
qualify to file as an indigent party. Contact Probate Court personnel for the required amount of
filing fees. If any objections are filed, a hearing will be (h eld on _____________________ ,
20 _____ ) (scheduled at a later date). If no objections are filed, the Petition may be granted without
a hearing. _________________________ ____________
Judge of the Probate Court
By: _________________________________
Clerk of the Probate Court
_________________________ ____________
_________________________ ____________
Address
_________________________ ____________
Telephone Number
GPCSF 9 [15] Eff. July 2017
IN THE PROBATE COURT OF _______________________ COUNTY
STATE OF GEORGIA
IN RE: ESTATE OF ) )
___________________________________ , ) ESTATE NO. ____________
DECEASED )
CERTIFICATE OF SERVICE
I certify that I have this date mailed (unless otherwise noted ) in an envelope with the proper
postage affixed thereto for first-class mail delivery copies of the Petition for Order Declaring No
Administration Necessary, Order fo r Service of Notice, including any attached Exhibits and the
Notice to the following partie s at the addresses below:
This _______ day of ________________, 20____.
_________________________ ____________
Clerk of the Probate Court
_____________________________________
_________________________ ____________
Address
_________________________ ____________
Telephone Number
GPCSF 9 [16] Eff. July 2017
Probate Court Retur
n Mailing Address:
________________________________ ________________________________
(Above space to be used for filing in Superior Court Clerk’s Office Deeds and Records)
IN THE PROBATE COURT OF _______________________ COUNTY
STATE OF GEORGIA
IN RE: ESTATE OF ) )
___________________________________ , ) ESTATE NO. ______________
DECEASED )
PETITION FOR ORDER DECLARING NO ADMINISTRATION NECESSARY
FINAL ORDER
A Petition for Order Declaring No Administration Necessary on the above estate was filed.
It appearing that the Decedent died intestate domiciled within, or domiciled outside the State of
Georgia but owning real property within, the above County; that all of the heirs of said Decedent
have agreed upon a division of the estate as evidenced by the A greement attached to the Petition
and incorporated herein by reference; that the estate of said Decedent owes no debts, except to
creditors, if any, including any security deed holders, who have consented or been served in this
matter; and that no objection has been filed.
ACCORDINGLY, IT IS ORDERED that No Administration is Necessary on the above
estate and by agreement of the parties the following interest hereby vests as follows:
GRANTOR: (NAME OF DECEDENT) ___________________________________ ________
ADDRESS OF THE DECEDENT _________________________________________________
GPCSF 9 [17] Eff. July 2017
GRANTEES: (For each person to receive an interest in any proper
ty according to the Agreement
and hereby Ordered by this Court)
_____________________________________________________________________________________
[Full Name of individual to receive interest]
_____________________________________________________________________________________
[Complete address including zip code of individual to receive interest]
_____________________________________________________________________________________
[Date of Birth or Majority Status] [Interest or percentage received pursuant to this Order]
--------------------------------------------------------------------------------------------------------- ------------
_____________________________________________________________________________________
[Full Name of individual to receive interest]
_____________________________________________________________________________________
[Complete address including zip code of individual to receive interest]
____________________________________________________________________________________ _________
[Date of Birth or Majority Status] [Interest or percentage received pursuant to this Order]
--------------------------------------------------------------- ------------------------------------------ ------------
____________________________________________________________________________________ _________
[Full Name of individual to receive interest]
____________________________________________________________________________________ _________
[Complete address including zip code of individual to receive interest]
____________________________________________________________________________________ _________
[Date of Birth or Majority Status] [Interest or percentage received pursuant to this Order]
--------------------------------------------------------------- ------------------------------------------ ------------
_____________________________________________________________________________________
[Full Name of individual to receive interest]
____________________________________________________________________________________ _________
[Complete address including zip code of individual to receive interest]
____________________________________________________________________________________ _________
[Date of Birth or Majority Status] [Interest or percentage received pursuant to this Order]
--------------------------------------------------------------------------------------------------------- ------------
GPCSF 9 [18] Eff. July 2017
Legal Description and Lo
cation of any Real Property:
IT IS FURTHER ORDERED that the Clerk shall send a certified cop y of this Order to the
Clerk(s) of the Superior Court(s) for recording on the deed rec ords of the following County(ies)
in which real property is located _____________________________ ______________________
___________________________________________________________________ County(ies).
SO ORDERED this _______ day of ________________, 20____.
_________________________ ____________
Judge of the Probate Court
GPCSF 9 [19] Eff. July 2017
IN THE PROBATE CO
URT OF _______________________ COUNTY
STATE OF GEORGIA
IN RE: ESTATE OF ) )
___________________________________ , ) ESTATE NO. ____________
DECEASED )
CERTIFICATION OF SERVICE OF ORDER
FOR NO ADMINISTRATION NECESSARY
I certify that I have this date mailed (unless otherwise noted ) in an envelope with the proper
postage affixed thereto for first-class mail delivery a certifi ed copy of the Order of No
Administration Necessary and the Agreement of the Parties in th e No Administration Necessary
to each party and county(ies) named below as addressed herein and deposited in the United States
Mail, with the return address of this Court thereon.
This _______ day of ________________, 20____.
_________________________ ____________
Clerk of the Probate Court
_______________________________________
_______________________________________
Address
_______________________________________
Telephone Number
