File No.
STATE OF NORTH CAROLINA
                                                                                                  In The General Court Of Justice
                                                County                                                    Superior Court Division
                                                                                                          Before The Clerk
             IN THE MATTER OF THE ESTATE OF
Name Of Decedent
                                                                                    APPLICATION AND ASSIGNMENT
                                                                                                  YEAR’S ALLOWANCE
Date Of Death
                                                                                                          G.S. 30-15, 30-16, 30-17, 30-21
I am applying for an allowance for a year’s support for the person(s) named and state:
1.     a. The decedent died a resident of this county on the date shown above.
       b.  The decedent did not die a resident of this county, but personal property that belonged to the decedent at his or her death, which was 
      on the date shown above, is located in this county.
2.   The surviving spouse, if any, named below is entitled to an allowance from the personal property of the decedent of the value of sixty 
   thousand dollars ($60,000), for a year’s support if the surviving spouse has not forfeited that right.* The child(ren), if any, named below is/are 
   entitled to an allowance of five thousand dollars ($5,000) for a year’s support.*
3.   I request assignment of 
       Sixty thousand dollars ($60,000) from the funds or other personal property of the decedent for a year’s support to the surviving spouse. 
       Five thousand dollars ($5,000) from the funds or other personal property of the decedent for a year’s support to each child named below.
                                       SPOUSE AND CHILD(REN)* ENTITLED TO ALLOWANCE
                Full Name                    Age Relationship                        Complete Address (including zip code)
                                                       Spouse

                                                         Child

                                                         Child

                                                         Child

                                                         Child

                                                         Child

                                                         Child
*NOTE: For a surviving spouse to be entitled to receive an allowance, he or she must have been a resident of North Carolina at the time of the decedent’s death, 
or the decedent must have been a resident of North Carolina at that time. See S.L. 2019-113. For a child to be entitled to receive an allowance, he or she must be 
one of the following: (1) a child under the age of 18 years, including an adopted child or a child with whom the widow was pregnant at the death of her husband; 
(2) a child who is less than 22 years of age who is a full-time student in any educational institution; (3) a child under 21 years of age who has been declared 
mentally incompetent; (4) a child under 21 years of age who is totally disabled; (5) a person under the age of 18 years who resided with the deceased parent at 
the time of death and to whom the deceased parent or the surviving parent stood in loco parentis. 
See G.S. 30-17 and G.S. 12-3(16), (17).
Name And Address Of Applicant (type or print)
                                                                     Spouse Of Decedent                    Child/Full-Time Student
                                                                     Personal Representative               Next Friend Of Child
                                                                     Guardian
                                                                     Other: 
By signing below, I agree that the information in this filing is true to the best of my knowledge, information, or belief. I understand that, in some 
circumstances, persons who make false filings can be subject to legal penalties or sanctions and, depending on the situation, may be charged 
with a crime.
Date                                                          Signature Of Applicant

                                                       Original-File   Copy-Applicant
                                                              (Over)

 AOC-E-100, Rev. 9/21
  © 2021 Administrative Office of the Courts

                                          ASSIGNMENT OF YEAR’S ALLOWANCE
I have examined the above application and have determined the money and other personal property of the decedent. I find that the 
allegations in the application are true and that each person(s) named in the application is entitled to the allowance requested.
I ASSIGN to the applicant the funds or other items of the personal property of the decedent listed below, which I have valued as 
indicated. This property is assigned free and clear of any lien by judgment or execution against the decedent and is to be paid by the 
applicant to the person(s) entitled. I assess as a DEFICIENCY the amount, if any, shown below, which is to be paid or delivered to the 
proper person when any additional personal assets of the decedent are discovered.
                              Personal Property Assigned                                                     Value

                                                                                                TOTAL      $
                                                                                   DEFICIENCY              $
Date Signature
                                                          Assistant CSC            Clerk Of Superior Court   Magistrate         SEAL
                                          CERTIFICATION
I hereby certify that the foregoing is a True and Correct copy of the report in the Assignment of Year’s Allowance in the matter of the 
above-referenced estate as recorded in this office and shall be sufficient to release the items listed as assigned to the surviving spouse 
or children of the deceased as provided under G.S. 30-15, 30-17, and 30-21.
Date Signature
                                                          Deputy CSC              Assistant CSC  Clerk Of Superior Court        SEAL

AOC-E-100, Side Two, Rev. 9/21
© 2021 Administrative Office of the Courts