Approved, SCAO

STATE OF MICHIGAN
PROBATE COURT
COUNTY OF

Estate of

SWORN STATEMENT TO CLOSE
UNSUPERVISED ADMINISTRATION
    SUPPLEMENTAL

JIS CODE:  SST

FILE NO.

1. I am the personal representative of this estate.  Upon filing this sworn statement with the court, this estate will be closed without

a hearing.  More than five months have passed since the date of the appointment of the original personal representative.

2. If required by law or court rule, I have published notice to creditors, and the time for presentment of claims has expired.

3. I have fully administered this estate by paying, settling, or disposing of the claims that were presented, the estate and administration

expenses, and all other taxes. I have distributed the assets of the estate to the persons entitled to the assets.*

4. The interested persons, addresses, and their representatives are identical to those appearing on the initial application/petition,

except as follows:

(Check only one box, as appropriate.)
5.

a. The decedent died before October 1, 1993, and no Michigan inheritance tax is due. A certificate of no inheritance tax liability

from the Michigan Department of Treasury is attached or has been filed.

b. The decedent died on October 1, 1993, or later and no Michigan estate tax is due.
c. Michigan estate or inheritance tax has been paid in full. (Evidence of full payment from Michigan Department of Treasury is attached or

has been filed.)

6. I sent a copy of this sworn statement to all distributees and to all claimants whose claims are neither paid nor barred and to all

demandants.  I furnished a full account in writing to the distributees whose interests are affected by the administration.

7. I reopened the estate and have completed the administration.

Personal representative signature

Personal representative name (type or print)

Sworn to before me on

Date

Date

Notary public, State of Michigan, County of

My commission expires:

Signature:

Address

City, state, zip

Attorney signature

Address

Telephone no.

  County, Michigan.

Attorney name (type or print)

Bar no.

City, state, zip

Telephone no.

NOTICE TO INTERESTED PERSON(S):  You may object to this sworn statement by filing written objections with the probate court
mentioned above along with a $20 filing fee. If an objection is not filed within 28 days after this sworn statement is filed with the court,
the probate register may issue a certificate stating that it appears that you have fully administered this estate.  The certificate does
not preclude any action against you or the surety on a bond you may have obtained.  If an action or proceeding involving you is not
pending in this court one year after this sworn statement is filed, your appointment ends.

*Note:  Specify any exceptions.  If any claims remain undischarged, state whether the estate was distributed subject to possible
liability with the agreement of the distributees, or state in detail other arrangements that were made to accommodate outstanding
liabilities.

Do not write below this line - For court use only

PC 591   (9/11)   SWORN STATEMENT TO CLOSE UNSUPERVISED ADMINISTRATION

MCL 700.3954, MCL 700.3958,
MCR 5.311(A), (C)