File No.
(TYPE OR PRINT IN BLACK INK)

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, Street Address, City, State And Zip Code Of Decedent                       AFFIDAVIT FOR COLLECTION OF 
                                                                                 PERSONAL PROPERTY OF DECEDENT
                                                                           (For Decedents Dying On Or Before Dec. 31, 2011)
Social Security No. (Last Four Digits) County Of Domicile At Time Of Death                 INTESTATE                              TESTATE
                                                                                                                                  G.S. 28A-25-1; 28A-25-1.1
Date Of Death                   Date Of Will                               Place Of Death (If Different From County Of Domicile)

Name, Street Address, PO Box, City, State And Zip Code Of Affiant 1        Name, Street Address, PO Box, City, State And Zip Code Of Affiant 2

Telephone No.                                                              Telephone No.

Legal Residence (County, State)                                            Legal Residence (County, State)

Name, Street Address, PO Box, City, State And Zip Code Of Attorney         Attorney Bar No.

                                                                           Telephone No.

I, the undersigned affiant, being first duly sworn, say that:
1. I am        an heir.         an executor named in the will.            a devisee named in the will.               the public administrator 
        a creditor of the decedent. I am not disqualified under G.S. 28A-4-2.
2. At least thirty (30) days have passed since the date of the decedent's death.
3. The decedent died             intestate.            testate.
4. (a)        The decedent died on or before 9/30/09 and the value of all personal property owned by the decedent less liens and 
              encumbrances thereon, does not exceed $10,000.
   (b)        I am the surviving spouse and sole heir/devisee of the decedent, the decedent died on or before 9/30/09, and the value of
              all personal property, less liens and encumbrances thereon, does not exceed $20,000.
   (c)        The decedent died on or after 10/1/09 and the value of all personal property owned by the decedent less liens and 
              encumbrances thereon, does not exceed $20,000.
   (d)        I am the surviving spouse and sole heir devisee of the decedent, the decedent died on or after 10/1/09, and the value of 
              all personal property, less liens and encumbrances thereon, does not exceed $30,000.
5. (Check if decedent died testate.) Decedent's will dated as shown above has been probated in each county in which is located any 
   real property owned by the decedent as of the date of death; and a certified copy of the decedent's will is attached to this 
   Affidavit.
6. No application or petition for appointment of a personal representative is pending or has been granted in any jurisdiction.
7. After diligent inquiry, I have determined that the persons listed below are all the persons entitled to share in the decedent's 
   estate.  (If there is a court-appointed guardian for any such person(s), list the guardian's name and address on an attachment.)
                 NAME                                      AGE             RELATIONSHIP                           MAILING ADDRESS

                                Original - File    Copy - Fiduciary    Copy - Clerk Mails Copy To Each Person Listed In Item No. 7
                                                                           (Over)
AOC-E-203A, Rev. 5/12
© 2012 Administrative Office of the Courts 

                                                  PRELIMINARY INVENTORY
(Give values as of date of decedent's death.  Continue on separate attachment if necessary.)
                                               PART . IPROPERTY OF THE ESTATE
1.   Accounts in sole name of decedent (List bank, etc., each account no. and balance.)                                                                                Est. Market Value
                                                                                                                                                                      $

2.   Joint accounts without right of survivorship (List bank, etc., each account no., balance and joint owners.)
                                                                                                                         % Owned By Dec.
                                                                                                                         % Owned By Dec.
                                                                                                                         % Owned By Dec.
                                                                                                                         % Owned By Dec.
  3. Stocks/bonds/securities in sole name of decedent or jointly owned without
     right of survivorship.............................................................................................  % Owned By Dec.
4.   Cash and undeposited checks on hand.........................................................................................................
5.   Household furnishings....................................................................................................................................
6.   Farm products, livestock, equipment and tools..............................................................................................
7.   Vehicles (include or attach descriptions)
8.   Interest in partnership or sole proprietor businesses......................................................................................
9.   Insurance, Retirement Plan, I.R.A., etc., payable to Estate...........................................................................
10.  Notes, judgments, and other debts due decedent..........................................................................................
11.  Miscellaneous personal property....................................................................................................................
12.  Real estate willed to the Estate....................................................................               $
13.  Estimated annual income of Estate................................................................................................................
                                               (Base bond on this amount, if applicable.)                                TOTAL PART I.                                $
            PART II.  PROPERTY WHICH CAN BE ADDED TO ESTATE IF NEEDED TO PAY CLAIMS
  1. Joint accounts with right of survivorship (List bank, etc., each account no., balance and joint owners.)
                                                                                                                                                                      $

 2.  Stocks/bonds/securities registered in beneficiary form and immediately transferred on death or jointly 
     owned with right of survivorship .....................................................................................................................
3.   Other personal property recoverable G.S. 28A-15-10 ...................................................................................
4.   Real estate owned by decedent and not listed elsewhere (attach description).................................................
                                                                                                                        TOTAL PART II.                                $
                                                  PART III. OTHER PROPERTY
1.   There        is         is   not  entireties real estate owned by decedent and spouse ..........................................
2.   There        are      are not   Insurance, Retirement Plan, I.R.A., accounts, etc., payable to named 
     beneficiaries....................................................................................................................................................
Signature Of Collector By Affidavit 1                                                   Signature Of Collector By Affidavit 2

Name (Type Or Print)                                                                    Name (Type Or Print)

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
                                                       CERTIFICATION
I certify that the foregoing is a true and accurate copy as taken from and compared with the original on record in this office.
Date                 Signature
                                                                                        Deputy CSC          Assistant CSC           Clerk Of Superior Court            SEAL
NOTE: This Affidavit for Collection of Personal Property of Decedent authorizes the named collector by affidavit to receive and administer ALL of the personal property 
belonging to the named decedent pursuant to G.S. Chapter 28A, Article 25.
AOC-E-203A, Side Two, Rev. 5/12
© 2012 Administrative Office of the Courts