Surviving Spouse Affidavit Of Assets (Estate 50K Or Less) {ESS-SSAoA}

Docket No.: State of New Jersey Essex County Surrogate's Court THEODORE N. STEPHENS, II SURROGATE Hall of Records, Room 206 Newark, New Jersey 07102 Phone 973-621-4900 Fax 973-621-2647 DEVERO D. MCDOUGAL DEPUTY SURROGATE In the matter of the Estate of: ____________________________, Deceased AKA: ______________________________ In Lieu of Administration Where Real and Personal Estate Does Not Exceed $50,000.00 (R.S. 3B:10-3) SURVIVING SPOUSE AFFIDAVIT OF ASSETS AND DECLARATION I, and say(s): 1. 2. I reside at , of full age, being duly sworn, depose(s) . I am surviving spouse/domestic partner of who died on ___________________, with a residence of______________________________in the County of Essex and State of New Jersey without leaving a Will. The decedent left no children or issue born to any person other than me. The parents of the decedent are not living, except as shown below: NAME Relationship ADDRESS/RESIDENCE 3. 4. 1 American LegalNet, Inc. www.FormsWorkFlow.com 5. The assets in the sole name of the decedent or held "as tenants in common" with decedent, known to me at this time, are as follows: TOTAL ESTIMATED AMOUNT/VALUE $ $ ITEMS Cash on hand: Balances in bank accounts of decedent (list accounts) Corporate Stocks, bonds and notes, etc: $ Life insurance taken out by decedent without A named beneficiary or payable to the Estate: $ Automobiles (include year, made, model, and VIN #): $ Household effects, jewelry, other chattel, etc.: $ All other personal property belonging to the Estate: (Refund checks, security deposits, etc.) $ Real Estate, located at (list separately by type and address): (If market value is unknown, may use tax assessed value) $ REMARKS: TOTAL VALUATION OFF ALL PROPERTY: 6. $ If any additional assets are discovered, the Surrogate's Court will be informed. Signature Subscribed and sworn to before me on this day of , 20 . Notary Public/Attorney at Law of New Jersey 2 American LegalNet, Inc. www.FormsWorkFlow.com