555 Blank Street Address Someplace, WI Form completed by: (Name) Mary Smith December 28, 2011 Address 555 Blank Street Date Someplace, WI 51111 Telephone Number Bar Number (If any) (715) 999-9999 N/A , 03/12 (Informal Administration or Formal 865.21, and 867.21, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, (DECEDENT'S COUNTY) COUNTY For Official Use Amended WILLIAM ELLIOTT, Informal Administration SAMPLE Formal Administration deceased Case No. 11PR111 1. I received from the personal representative special administrator of this estate the following: Describe of property or monies received 2009 ACME GTS automobile - VIN 2010GB543W789 $26,500.00 Antique Shaker corner cabinet, silver dollar collection, sterling silver tea set, appliances 19,100.00 ¼ residual share 38,709.82 2. This is a partial full distribution of my share of the estate. 3. This is a full satisfaction of the claim filed by _________________________ in the amount of $___________. . 4. This is a distribution of funds to trust. (Identify Trust) . 5. Other: Signature Brown Name Printed or Typed 100 Second Street Address Someplace, WI 51111 Form completed by: (Name) Mary
555 Blank Street Address Someplace, WI Form completed by: (Name) Mary Smith Address 555 Blank Street Someplace, WI 51111 December 28, 2011 Date Telephone Number (715) 999-9999 Bar Number (If any) N/A , 03/12 (Informal Administration or Formal 865.21, and 867.21, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. STATE OF WISCONSIN, CIRCUIT COURT, (DECEDENT'S COUNTY) COUNTY For Official Use SAMPLE WILLIAM ELLIOTT, Amended Informal Administration Formal Administration deceased Case No. 11PR111 1. I received from the personal representative special administrator of this estate the following: Describe of property or monies received 2009 ACME GTS automobile - VIN 2010GB543W789 $26,500.00 Antique Shaker corner cabinet, silver dollar collection, sterling silver tea set, appliances 19,100.00 ¼ residual share 38,709.82 2. This is a partial full distribution of my share of the estate. 3. This is a full satisfaction of the claim filed by _________________________ in the amount of $___________. 4. This is a distribution of funds to trust. (Identify Trust) . 5. Other: . Signature Brown Name Printed or Typed 100 Second Street Address Someplace, WI 51111 Form completed by: (Name) Mary
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