Fill and Sign the Surrogates Court of the State of New York County of Form

SURROGATE’SSURROGATE ’S COURT OF THE STATE OF NEW YORK COUNTY OF _______________________________ -----------------------------------------------------------------x In the Matter of INVENTORY OF ASSETS (Rule §207.20) Deceased. -----------------------------------------------------------------x File N o:_____________________________ T he undersigned, a fiduciary or attorney for the fiduciary of the above Decedent’s estate, certifies that the following constitutes the gross estate for tax purposes and identifies whether non-estate assets exist. Complete below according to the following value categories: Category A - under $10,000; Category B - $10,000 to under $20,000; Category C - $20,000 to under $50,000; Category D - $50,000 to under $100,000; Category E - $100,000 to under $250,000; Category F - $250,000 to under $500,000; Category G - $500,000 or over. Date of Death:____________ Date of Letters:____________ Type of Letters:______________________________ Name of Fiduciary(ies) and, if changed, fiduciary(ies) address: _____________________________________________ ASSETS INDIVIDUALLY OWNED BY DECEDENT OR PAYABLE TO ESTATE CATEGORY 1. Real Estate ___________ 2. Stocks and Bonds ___________ 3. Insurance Payable to Estate ___________ 4. IRAs, 401 Ks Payable to Estate ___________ 5. Mortgages or Notes Held by Decedent ___________ 6. Cash ___________ 7. Miscellaneous ___________ 8. Firearms (Check appropriate box) Yes – see attached firearms inventory None *TOTAL ESTATE ASSETS ___________ NON-ESTATE ASSETS - CHECK YES OR NO TO EACH OF THE FOLLOWING: 9. Living Trust Yes No If yes, set forth the Name of the Trustee(s) ____________________________________________ 10. Gifts in Excess of Federal Annual Exclusion Made Within 3 Years of Decedent’s Death Yes No 11. Jointly Held Property (Real or Personal) Yes No 12. Insurance Payable to Beneficiary Yes No 13. IRAs, 401K’s Payable to Beneficiary Yes No 14. Annuities Yes No 15. Powers of Appointment Yes No 16. Cause(s) of Action Pending Yes No If yes, identify Court and Index Number ____________________________________________ Certified to be true on the ______ day of _____________________, 20____. ________________________________________ ____________________________________________________ Signature Attorney ’s Name ________________________________________ ____________________________________________________ Print Name Attorney ’s Address ____________________________________________________ I-1 3/2016 Attorney ’s Telephone No. TO BE COMPLETED BY FIDUCIARY or ATTORNEY FOR FIDUCIARY Total Estate Assets (see below)* __________ Filing fee SCPA 2402(7) $__________ Filing fee initially paid $__________ Balance (Refund) Due $__________ $0.00