Fill and Sign the This Form Has Been Officially Prescribed by the Supreme Court of Arkansas for Use under the Probate Cede Act 140 of the 1949

OFFICIAL PROBATE FORM 17 — Page 1 PROBATE CODE, SEC. 91 This Form Has Been Officially Prescribed by the Supreme Court of Arkansas for Use Under the Probate Cede, Act 140 of the 1949 Acts of Arkansas.Note: To be filed by personal representative within two months after qualification. Probate Code, Section 91, requires each personal representative to file a true and complete inventory of all property owned by the decedent at the time of his death,... describing each item of property in detail and setting out the personal representative's appraisement of the fair market value thereof as of the date of death of the decedent." IN THE PROBATE COURT OF __________________ COUNTY, ARKANSAS _____________________DISTRICT IN THE MATTER OF THE ESTATE OFNo. ___________________________________________________________, deceased INVENTORY OF DECEDENT'S ESTATE The undersigned,______________________________________________________________ , of the estate of ___________________________________________, deceased, states on oath that to the best of my knowledge and belief, the following is a complete and accurate inventory of all property owned by the decedent, and its fair market value, at the time of the decedent's death. REAL ESTATE LEGAL DESCRIPTION ENCUMBRANCES, LIENS, ETC., AND RESPECTIVE AMOUNTS THEREOFNET VALUEHomestead: $ Other real estate: Total value of real estate ............ $ OFFICIAL PROBATE FORM 17 — Page 2 (Continued Next Page) PERSONAL PROPERTY LEGAL DESCRIPTION ENCUMBRANCES, LIENS, ETC., AND RESPECTIVE AMOUNTS THEREOFNET VALUE HOUSEHOLD GOODS AND PERSONAL EFFECTS (This list should include but not be limited to furniture, household and yard equipment, clothing, jewelry, etc.) $ OTHER TANGIBLE PERSONAL PROPERTY (This list should include, but not be limited to, automobiles and other motor vehicles, farm equipment, livestock, agricultural products, stocks of merchandise, any going business enterprise or interest therein, etc.) $ OFFICIAL PROBATE FORM 17 — Page 3 TANGIBLE PERSONAL PROPERTY (Note:List separately in detail: cash on hand; money on deposit, stating names and addresses of depositories; bonds, stating names of issuers, interest rates, classes, maturity dates, serial numbers, face amounts, and dates to which interest is paid; corporate stocks, stating certificate numbers, names of issuers, classes, and number of shares; notes receivable, stating the names and addresses of makers, dates, amounts, interest rates, and dates to which interest paid, balance due, maturities, and security, if any; accounts receivable, stating names of debtors, dates of last items, and balances due, and other intangibles, describing in detail.) $ ____________ Total value of personal property $ ____________ OFFICIAL PROBATE FORM 17 — Page 4 SUMMARY Total real property ...................................................... $ _____________Total personal property .............................................. $ _____________Total Estate .................................................... $ _____________The undersigned was not indebted or obligated to the decedent at the time of the decedent's death except as stated hereinDATED this _________________ day of _______________________________, ________. STATE OF ARKANSAS COUNTY OF _____________________Subscribed and sworn to before me on ________________ day of _____________, ___________________________________________________(SEAL)__________________________________________ (Official Title)