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                                                              AFFIDAVIT OF COLLECTION,
                                                                      DISBURSEMENT AND DISTRIBUTION
                                                                                                                                                               G.S. 28A-25-3(a)(2)
I, the undersigned collector by affidavit, being first duly sworn, say that the following is a complete and accurate account of my receipts, 
disbursements, and distributions as collector by affidavit of the personal property of this estate.
Accounting Period From                                            Extending To

                                                          PART I. SUMMARY
1. Total Personal Property Received as shown in Part II ...................................................................................................... $

2. Minus Spousal Allowance Approved By The Court Under G.S. 30-15 ....................................................................–                        $

3. Minus Disbursements (Debts or Expenses) as shown in Part III ............................................................................–                  $

4. Minus Distributions To Heirs as shown in Part IV ...................................................................................................–       $

5. BALANCE AT THE END (this will always be zero)                                                                                                               $
                                            PART II. PERSONAL PROPERTY RECEIVED
Date Received           Received From                                         Description                                                                       Value
                                                                                                                                                               $

                                                                              TOTAL RECEIPTS                                                                   $

                                                                (Over)
AOC-E-204, Rev. 4/19, © 2019 Administrative Office of the Courts

                                PART III. DISBURSEMENTS (DEBTS OR EXPENSES)
Date Paid                       To                                              For                               Amount
                                                                                                                 $

                                                                                TOTAL DISBURSEMENTS              $

                                          PART IV. BALANCE DISTRIBUTED TO HEIRS
                                                  Heirs                                                           Amount
                                                                                                                 $

                                                                                                 TOTAL BALANCE   $
Signature Of Affiant 1                                                    Signature Of Affiant 2

SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME                                SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME
Date                   Signature Of Person Authorized To Administer Oaths Date                   Signature Of Person Authorized To Administer Oaths

      Deputy CSC        Assistant CSC      Clerk Of Superior Court              Deputy CSC        Assistant CSC  Clerk Of Superior Court
        Date Commission Expires                                           Date Commission Expires
 Notary                                                                                                                                            Notary
        County Where Notarized                                            County Where Notarized
SEAL                                                                                                              SEAL

AOC-E-204, Side Two, Rev.  /194
© 2019 Administrative Office of the Courts