Form 74 - Report Of Personal Representative Of Decedent (Page 2 of 2) in pdf

Form 74 - Report Of Personal Representative Of Decedent Page 2

Form 74 Page 2

B. Bank Deposits

- List accounts in financial institutions.

Name of bank or other institution

Type of account

Balance at date of death

Total Value

$ __________________

C. Securities

- List all stocks, bonds, and other securities that were owned by the decedent.

Name of company

Number of shares

Value at date of death

Total Value

$ __________________

D. Other Assets

- List other assets (household furnishings, motor vehicles, and other personal property).

Total Value

$ __________________

E. Insurance

- Insurance on decedent's life (owned by the decedent).

Total Value

$ __________________

Under penalty of perjury, I declare that I have examined this report, including any accompanying schedules and statements, and to the best of my

knowledge and belief, it is true, correct, and complete.

Personal Representative / Surviving Joint Tenant / Attorney

Name (typed or printed)

Social security number or federal employer identification number

Address

City

State

ZIP code

Signature of representative

Date

Phone number

ADOR 06-0034 (00)

Form 74 - Report Of Personal Representative Of Decedent Page 2