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

                                                                                        PARTI. SUMMARY
1. Total Personal Property Received As Shown in Part  II............................................................................
                                                                                                                                                                                                                                    $
2. M n i u S   s pous  o l l A   l a wanc A   e p o r p ve B   d T   y h   e Co   t r u Und   r e G 3   . S . 1 - 0 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    5 _
                                                                                                                                                                                                                                    $
3. Minus Disbursements (Debts or Expense) 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

                                                                                (Over)
                                                                                                                    TOTAL RECEIPTS                                                                                                   $
AOC-E-204, Rev. 1/12
© 2012 Administrative Office of the Courts

                                   PART III. DISBURSEMENT (DEBTS OR EXPENSE)
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                                                     Date                  Signature

     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. 1/12
© 2012 Administrative Office of the Courts