Fill and Sign the Personal Property Held by or in the Possession of the Decedent as Fiduciary or Trustee Exempt Property Family Form

JDF 966 SC R6/19 STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE Page 1 of 2 ❑ District Court ❑ Denver Probate Court ____________________ County, Colorado Court Address: In the Matter of the Estate of : Deceased COURT USE ONLY Attorney or Party W ithout Attorney (Name and Address): Phone Number: E -mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE PURSUANT TO §15 -12 -1204 , C.R.S I, (personal representative ), state the following : 1. The value of the entire estate of the decedent, less liens and encumbrances, did not exceed the value of personal property held by or in the possession of the decedent as fiduciary or trustee, exempt property, family allowance, costs and expenses of administration, reasonable funeral expenses , and reasonable and necessary medical and hospital expenses of the last illness of the decedent. 2. The undersigned has fully administered this estate by disbursing and distributing it to the persons entitled. 3. The undersigned has sent a copy of this statement to all distributees of this estate and to all creditors or othe r claimants to whom the undersigned is aware whose claims are neither paid nor barred and has furnished a full account in writing of the undersigned’s administration to the distributees whose interests are affected. 4. No court order prohibits the informal c losing of this estate. Administration of this estate is not supervised. This statement is filed for the purpose of closing this estate. The appointment of the personal representative will terminate one year after this statement is filed with the court if no proceedings involving the undersigned are then pending. ❑ By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. ❑ By checking this box, I am acknowledging that I have made a change to t he original content of this form . VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the ______ day of Executed on the ______ day of (date) (date) _______________________, _________, _______________________, _________, (month) (year) (month) (year) at ______________________________________ at ______________________________________ (city or oth er location, and state OR country) (city or other location, and state OR country) JDF 966 SC R6/19 STATEMENT OF PERSONAL REPRESENTATIVE CLOSING SMALL ESTATE Page 2 of 2 _______________________________ _______________________________ (printed name) (printed name) _______________________________ _______________________________ (Signature of Personal Representative ) (Signature of Co -Personal Representative , if any) CERTIFICATE OF SERVICE I certify that on ___________________ (date), a copy of this _______________ (name of document) was served as follows on each of the following: Name and Address Relationship to Decedent, Ward, or Protected Person Manner of Service* *Insert one of the following: hand delivery, first -class mail, certified mail, e -service, or fax. ___________________________________________ Signature Note : • This form is to be used only if a probate estate has been opened and a Persona l Re presentative has been appointed.