Inventory

Form RW-09 eff. 09.01.16 Donald Petrille, Jr., Esquire Register of Wills of Bucks County, Pennsylvania INVENTORY Return Completed Form to the Register of Wills within nine (9) months of date of death COMMONWEALTH OF PENNSYLVANIA SS COUNTY OF BUCKS File Number: The undersigned, , Personal Representative(s) of the Estate of , deceased, depose(s) and say(s) that the items appearing in the following Inventory include all of the personal assets wherever situated and all of the real estate in the Commonwealth of Pennsylvania of said Decedent, that the valuation placed opposite each item of said Inventory represents its fair value as of the date of the decedent222s death, and that Decedent owned no real estate outside of the Commonwealth of Pennsylvania except that which appears in a memorandum at the end of this Inventory. Corporate Fiduciary (if applicable) I verify that the statements made in this Inventory are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 247 4904 relating to unsworn falsification to authorities. Name of Corporate Fiduciary Signature of Personal Representative Name of Representative and Title Signature of Personal Representative Signature of Officer/Representative Date Attorney -- (Name) (Supreme Court I.D. No.) (Name of Law Firm) (Address) (Telephone) (Email) DATE OF DEATH LAST RESIDENCE DECEDENT222S SOCIAL SECURITY NO. ALL FIGURES MUST BE TOTALED ITEM NO. DESCRIPTION DOLLAR VALUE TOTAL: NOTE: The Memorandum of real estate outside the Commonwealth of Pennsylvania may, at the election of the personal representative include the value of each item, but such figures should not be extended into the total of the Inventory. (See 20 Pa.C.S. 247 3301(b)) (See Reverse side for additional space) ALL FIGURES MUST BE TOTALED American LegalNet, Inc. www.FormsWorkFlow.com Form RW-09 eff. 09.01.16 ITEM NO. DESCRIPTION DOLLAR VALUE TOTAL (Attach additional sheets as needed) American LegalNet, Inc. www.FormsWorkFlow.com