Fill and Sign the Table of Contents Permanency Planning Duke Law Form

Deputy CSC Assistant CSC Clerk of Superior Court Assistant CSCClerk of Superior Court Signature Date SEAL Deputy CSC Assistant CSC Clerk Of Superior Court Notary CLERK'S REVIEW AND APPROVAL I have reviewed the List of Phase II Distributees and determined that the list of distribut es and their shares of potential Phase II payments are in accordance with the will of the decedent , or if there is no will, in accordance with the Intestate Succession Act. The List is accepted for filing, is approved, and the estate is closed. Signature Date I certify that this is a true copy of the original List of Phase II Distributees on file in this office. CERTIFICATION LIST OF PHASE II DISTRIBUTEES In The General Court Of Justice Superior Court DivisionBefore The Clerk County G.S. 28A-21-3.1 IN THE MATTER OF THE ESTATE OF: AOC-E-910M, Rev. 3/07 © 2003 Administrative Office of the Courts 5. Name Address (If Known) Relationship to Decedent Percentage Of PaymentEntitled To Receive SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME Signature Of Personal Representative Or Collector Date Signature Of Person Authorized To Administer Oaths SEAL Date Decedent's Social Security Number Name Of Decedent The undersigned being duly sworn or affirmed states that : The names and addresses of devisees or heirs of the decedent entitled to receive Phase II payments and the percentage of the Phase II payments to be received by each are listed below. (Attach additional sheets if necessary.) 1. I am the duly authorized personal representative or col lector by affidavit of the above-referenced estate. 2. There are no unsatisfied creditors. 3. There are no unsatisfied general monetary bequests. 4. All assets other than any potential Phase II payments have been distributed. Name And Address Of Personal Representative Or Collector By Affidavit Date My Commission Expires County Where Notarized NOTE: If an heir/devisee is under the age of 18 at the time hereof, or if the heir/devisee has been declared incompet ent, you must also list a person authorized by law to receive funds on behalf of a minor or incompetent. See Side Two. File No. STATE OF NORTH CAROLINA AOC-E-910M, Side Two, Rev. 3/07 © 2007 Administrative Office of the Courts Name Address (If Known) Relationship to Decedent Percentage Of Payment Entitled To Receive ADDITIONAL HEIRS Persons Authorized By Law To Receive Funds For Minor Or Incompetent. The following persons are authorized by law to receive funds on behalf of a minor or incompetent: 1. 2. 3. 4. 5. A court appointed guardian of the estate or general guardian [ G. S. 35A-1251 and 1252]. The parent of a minor, if: a) the minor is residing in the same hou sehold with the parent, b) the cumulative total of all distributions from the estate listed on Side One, including the current or pend ing distribution, does not exceed $1,500, c) the decedent died without a will, and d) the distribution is approved by the clerk of superio r court [G. S. 28A-27-7]. A parent, guardian, or person having custody of a child or incompete nt, if the will of the decedent named on Side One authorizes such distribution [G.S. 32-26 and 27]. The clerk of superior court, acting on behalf of a minor without a gu ardian [G. S. 28A-23-2]. The clerk of superior court or public guardian, acting on behalf of an incapacitated adult for whom there is no guardian, if the amount of the current or pending distribution is $5,000 or less [G. S. 7A-1 11].