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SAMPLE DOCUMENT – FOR INFORMATION ONLY1Name, Address and Telephone Number of Person Without Attorney:2345In Pro Per678SUPERIOR COURT OF THE STATE OF CALIFORNIA9COUNTY OF SANTA CLARA101112In the Matter of the Estate of131415Decedent.16171819)))))))))))))))Case No.:(FIRST AND FINAL ACCOUNT/WAIVER OFACCOUNT) AND REPORT OF(EXECUTOR/ADMINISTRATOR/ADMINISTRATOR- WITH-WILL ANNEXED),PETITION FOR (ALLOWANCE OFSTATUTORY FEES TO PERSONALREPRESENTATIVE AND FOR) FINALDISTRIBUTIONDate:Time: 9:00 a.m.Dept.The petition of [name of personal ator-with-will-annexed]21[name of decedent], asof the Estate of, deceased alleges:221. DATE OF DEATH AND DOMICILE.23[name of decedent]died on [date]24the City of, County of25was a resident of that county at the time of [his/her], State of California, anddeath.262. APPOINTMENT OF PERSONAL REPRESENTATIVE.27The decedent's Will dated282930inand codicil dated[was/were] admitted probate by order of this court on [date Order for Probate was entered]1First and Final Account/Waiver of Account) and Report of (Executor/Administrator/ Administrator- with-willannexed), Petition for (Allowance of Statutory Fees to Personal Representative and for) Final Distribution

SAMPLE DOCUMENT – FOR INFORMATION ONLY1[OR: Despite search and inquiry, no will of decedent has been found].Petitioner qualified -annexed]3Testamentary/Letters of Administration/Letters of Administration-with-will-annexed]4were issued to petitioner on [date Letters were issued]5then petitioner have been acting as the duly qualified nnexed]789of the estate and [Letters. At all times sinceof the decedent’s estate.3. AUTHORITY GRANTED UNDER INDEPENDENT ADMINISTRATION OFESTATES ACT.On [date Order for Probate was signed], petitioner was granted authority by10order of this court to administer the estate without court supervision under the Independent11Administration of Estates Act. This authority has not been revoked.124. STATUS OF ESTATE.13Petitioner has performed all duties required of [him/her] for the estate of the decedent14with respect to the administration of the estate. The estate is now ready for distribution and15is in a condition to be closed.165. NOTICE OF DEATH.17Notice of Petition to Administer Estate, which constitutes one form of notice to18creditors, has been published for the period and in the manner prescribed by law. Within19thirty (30) days after the completion of publication, an Affidavit of Publication showing due20publication in the manner and form required by law was filed with the clerk of the court.21Reasonable efforts were made to identify creditors of the estate and Notice of Administration22to Creditors was sent to all known creditors of the estate on [date or dates when Notice was mailed]2324. More than four months have elapsed since the first issuance ofLetters, and the time for filing or presenting claims has expired.256. CREDITORS' CLAIMS.26[All/No/The following]27claims have been filed with the court or presented to the personalrepresentative:2829302First and Final Account/Waiver of Account) and Report of (Executor/Administrator/ Administrator- with-willannexed), Petition for (Allowance of Statutory Fees to Personal Representative and for) Final Distribution

SAMPLE DOCUMENT – FOR INFORMATION ONLY1Name of CreditorDate Claim FiledPurposeAmount2347.COMPLIANCE WITH PROBATE CODE §9202.5Notice to the Director of Health Services is not required under Probate Code Section 92926because the decedent did not receive and was not the surviving spouse of someone who7received Medi-Cal benefits /or/ Notice to the Director of Health Services has been given as8required by law under Probate Code Section 9202. A notice was received from the Director9of Health Services stating that no creditor’s claim will be filed against the estate because10decedent has not received any Medi-Cal benefits. Petitioner sent no notice of the decedent’s11death to the Director of the California Victim Compensation or to the Government Claims12Board under Probate Code section 9202(b), because no heir is confined in a prison or facility13under the jurisdiction of the Department of Corrections or the Department of the Youth14Authority or confined in any county or city jail, road camp, industrial farm, or other local15correctional facility. /or/ Notice to the Director of the California Victim Compensation or to16the Government Claims Board has been given under Probate Code section 9202(b). No17creditor’s claim has been received or the creditor’s claim of has been paid as set18forth above. Petitioner sent the notice to the Franchise Tax Board required by Probate Code19section 9202(c) as provided in section 1215 on , 20 .208. DEBTS OF DECEDENT.21All debts of decedent and of the estate and all expenses of administration, except22closing expenses and statutory commissions of the personal representative [and their attorneys]23have been paid.249. INVENTORY AND APPRAISAL.25An Inventory and Appraisal was returned and filed on [date inventory was filed]26showing a value of . [If additional inventories filed, add: A27Supplemental Inventory and Appraisal was filed in the amount of 28estate of 2930.]for total assets belonging to thePetitioner alleges that such [inventory/inventories] contain all3First and Final Account/Waiver of Account) and Report of (Executor/Administrator/ Administrator- with-willannexed), Petition for (Allowance of Statutory Fees to Personal Representative and for) Final Distribution

SAMPLE DOCUMENT – FOR INFORMATION ONLY1the assets of decedent's estate that have come to petitioner's knowledge or into [his/her]2possession.310. ACTIONS TAKEN UNDER INDEPENDENT ADMINISTRATION OFESTATES ACT.4[Describe action taken, for example: Decedent's real property located at56was sold to7]for , on (date)under the Independent Administration of Estates Act. A Notice of Proposed8Action was given as prescribed by law to the persons entitled to receive notice. No objections9to the sale were received. [Add, if applicable: The net proceeds of sale will be distributed as part of the residue of10the decedent's estate.]1111. PERSONAL PROPERTY TAXES.12All personal property taxes due and payable by this estate have been paid /or/ No13personal property taxes are due and payable by this estate.1412. CALIFORNIA AND FEDERAL ESTATE TAXES.15A federal estate tax return, Form 706, has not been filed because the estate is not16sufficient to require such a return. No California estate taxes are due and payable by this17estate.1813. INCOME TAXES.19All California and federal income taxes due and payable by the estate will be paid by20the personal representative from decedent's estate prior to distribution /or/ No California or21federal income taxes are due and payable by the estate.2214. INVESTMENT OF CASH ON HAND.23Petitioner has invested and maintained all cash in interest bearing accounts or in24investments authorized by law or the governing instrument, except for an amount of cash25that is reasonably necessary for the orderly administration of the estate.2615. WAIVER OF ACCOUNT. [if applicable]27[Name(s)],282930the person(s) entitled to distribution of all of the estate, waive(s) an account bypetitioner, which waiver(s) [are on file/will be filed] in this proceeding.4First and Final Account/Waiver of Account) and Report of (Executor/Administrator/ Administrator- with-willannexed), Petition for (Allowance of Statutory Fees to Personal Representative and for) Final Distribution

SAMPLE DOCUMENT – FOR INFORMATION ONLY115. SUMMARY OF ACCOUNT. [if account not waived]2Petitioner is chargeable with and is entitled to the credits set forth in the Summary of3Account below. The account covers the period from [date of death]4[end of period covered by account]5Summary of Account are attached hereto and incorporated herein by this reference.:6. Schedules A throughtoin support of theCHARGES7Inventory and Appraisal 8Supplemental Inventory and Appraisal (if any) 9Additional Property Received (if any) 10Income Receipts During Account Period(Schedule A) 11Gains on Sales or Other Disposition of Assets(Schedule B) 12Net Income from Trade or Business (if any)(Schedule C) 13Total Charges14 CREDITS15Disbursements During Accounting Period(Schedule D) 16Losses on Sales or Other Disposition of Assets (Schedule E) 17Net Loss from Trade or Business (if any)(Schedule F) 18Distributions to Beneficiaries (if any)(Schedule G) 19Property on Hand at End of Accounting Period (Schedule G) 20Total Credits2116. CHARACTER OF PROPERTY.22The whole of the estate is decedent's [separate/one-half interest in the community property of decedent23 and his/her surviving spouse/quasi-community] property [or describe interests, if mixed].2417. SCHEDULE OF PURCHASES OR OTHER CHANGES IN FORM OFASSETS.25Certain assets were disposed of or changed in form during the administration of the26estate. All changes in investments are shown on Attachment27and made a part hereof by reference., attached hereto2829305First and Final Account/Waiver of Account) and Report of (Executor/Administrator/ Administrator- with-willannexed), Petition for (Allowance of Statutory Fees to Personal Representative and for) Final Distribution

SAMPLE DOCUMENT – FOR INFORMATION ONLY118. INTESTATE HEIRS/DEVISEES UNDER WILL.2The following are the [decedent’s heirs under the laws of intestate succession/devisees named in3the decedent’s Will]:4NameAge5RelationshipAddress6789101119. PROPOSED DISTRIBUTION OF ESTATE.12131415[By the terms of the decedent’s will/Pursuant to the laws of intestate succession],the estate should bedistributed [as follows/as shown on Attachment ].NameDescription of Share of Estate161718192021222324252627282930The residue of the estate, insofar as is known to petitioner, consists of the assets listedon [Scheduleof the account/Attachment].20. COMPUTATION OF STATUTORY COMPENSATION.The statutory -will-annexed’s] compensation [and thestatutory attorneys’ compensation – if applicable],payable [to each] for their services are , computed on a fee base of , arrived at as follows:FEE BASEInventory and Appraisal Supplemental Inventory (if any) 6First and Final Account/Waiver of Account) and Report of (Executor/Administrator/ Administrator- with-willannexed), Petition for (Allowance of Statutory Fees to Personal Representative and for) Final Distribution

SAMPLE DOCUMENT – FOR INFORMATION ONLY1Income Receipts During Account Period 2Gains on Sales 3Less: Losses on Sale 4TOTAL FEE BASE 5FEE COMPUTATION64% of first 100,000 4,000.0073% of next 100,000 3,000.0082% of next 800,000 91% of next 1,000,000 to 10,000,000 TOTAL FEE 101121. STATUTORY [EXECUTOR’S/ADMINISTRATOR’S] COMPENSATION12Petitioner should be authorized to pay [himself/herself] the sum of 13as and for ordinary services rendered to the estate in discharge of this obligation /or/14By [his/her] signature on this petition, petitioner waives [his/her] right to statutory commissions15as [executor/administrator/ administrator-with-will-annexed].1617181922. DISCLOSURE OF RELATIONSHIPS BETWEEN FIDUCIARY, ATTORNEYS,AND OTHER AGENTS HIRED BY FIDUCIARYPetitioner has no personal, financial or other relationship with attorneys or otheragents hired by the petitioner.2023.21Petitioner asks that [he/she]2223CLOSING EXPENSES.be authorized to withhold the sum of to offset closing costs and expenses, and as a reserve for any liability that mayhereafter be determined to be due from this estate.2424. SPECIAL NOTICE.25[No one – or list names of person]26WHEREFORE, petitioner prays for an order of this court that:271. The administration of this estate be brought to a close [if accounting has been waived, add:282930has filed a Request for Special Notice.“without the requirement of an accounting by the exed”];7First and Final Account/Waiver of Account) and Report of (Executor/Administrator/ Administrator- with-willannexed), Petition for (Allowance of Statutory Fees to Personal Representative and for) Final Distribution

SAMPLE DOCUMENT – FOR INFORMATION ONLY12. The [list caption of document, for example: (FIRST AND FINAL ACCOUNT/WAIVER OF ACCOUNT)2AND REPORT OF (EXECUTOR/ADMINISTRATOR/ ADMINISTRATOR- WITH-WILL ANNEXED), PETITION3FOR (ALLOWANCE OF STATUTORY FEES TO PERSONAL REPRESENTATIVE AND FOR) FINAL4DISTRIBUTION]563. All the acts and proceedings of petitioner as exed]78be settled, allowed, and approved as filed;be confirmed and approved;4. Petitioner shall be authorized to withhold to defray closingexpenses and to pay any additional liabilities;95. [if applicable]Petitioner shall be authorized and directed to pay [himself/herself] the sum10of 11rendered in the administration of this estate., representing statutory compensation for ordinary services126. Distribution of the estate of decedent in petitioner's hands and any other property13of decedent or the estate not now known or discovered be made to the persons entitled to it,14as set forth in the petition; and that1516177. Such further order be made as the court considers proper.Dated:.[name], Petitioner181920212223242526272829308First and Final Account/Waiver of Account) and Report of (Executor/Administrator/ Administrator- with-willannexed), Petition for (Allowance of Statutory Fees to Personal Representative and for) Final Distribution

SAMPLE DOCUMENT – FOR INFORMATION ONLY1VERIFICATIONCCP 446, 20l5.523I declare that:4I am the nexed] of the above-entitled estate. I5have read the foregoing [(FIRST AND FINAL ACCOUNT/WAIVER OF ACCOUNT) AND REPORT OF6(EXECUTOR/ADMINISTRATOR/ ADMINISTRATOR- WITH-WILL ANNEXED), PETITION FOR (ALLOWANCE7OF STATUTORY FEES TO PERSONAL REPRESENTATIVE