New York Codes, Rules and Regulations
Title 22 - JUDICIARY
Subtitle D - Forms
Chapter VII - Surrogate's Court Forms
Subchapter A - Forms Authorized By Section 207.52
Surrogate's Forms
Form ADM/DBN-1 - Petition for letters of administration d.b.n
For Office Use Only
(Filing Fee Paid $ ____________)
____________ Certs: $ ____________
$ ____________ Bond, Fee: ____________
Receipt No: ____________ No: ____________
DO NOT LEAVE ANY ITEMS BLANK
SURROGATE'S COURT OF THE STATE OF NEW YORK PETITION FOR
COUNTY OF LETTERS OF
ADMINISTRATION d.b.n.
SCPA 1007
________X
LETTERS OF ADMINISTRATION d.b.n.
ESTATE OF:
[ ] Letters of Administration d.b.n.
a/k/a [ ] Letters of Administration d.b.n. with Limitations
[ ] Limited Letters of Administration d.b.n.
Deceased. File No. ________
________X
TO THE SURROGATE'S COURT, COUNTY OF :
It is respectfully alleged:
1. (a) The name, citizenship, domicile (or, in the case of a bank or trust company, its principal office) and interest in this proceeding of the petitioner(s) is/are as follows:
Name: ____________
Domicile or Principal Office: ____________
(Street and Number) (City, Village, Town)
____________
(County) (State) (Zip Code) (Telephone Number)
Mailing address: ____________
(if different from domicile)
Citizenship (check one): [ ] U.S.A. [ ] Other (specify) ____________
Domicile or Principal Office: ____________
(Street and Number) (City, Village, Town)
____________
(County) (State) (Zip Code) (Telephone Number)
Mailing address: ____________
(if different from domicile)
Citizenship (check one): [ ] U.S.A. [ ] Other (specify) ____________
Interest(s) of Petitioner(s): [Check one]
[ ] Distributee of decedent (state relationship) ____________
[ ] Other [Specify] ____________
1. (b) Is the proposed Administrator d.b.n. an attorney? Yes [ ] No [ ]
[NOTE: If yes, submit statement pursuant to 22 NYCRR 207.16(e); see also 207.52]
2. Letters of Administration of the above-named decedent were issued by this court on ________, to ________, who on ____________,
[ ] died [ ] resigned [ ] was removed.
ADM/DBN-1 (7/98) -1-
[Note: For paragraphs 3a through c: Do not include any assets that are jointly held, held in trust for another, or have a named beneficiary.]
3. (a) The estimated gross value of unadministered personal property passing by intestacy is less than
$ ________.
(b) The estimated gross value of the decedent's unadministered real property, in this state, which is [ ] improved [ ] unimproved, passing by intestacy is less than
$ ________.
A brief description of each parcel is as follows:
(c) The estimated gross rent for a period of eighteen (18) months is the sum of
$ ________.
(I) [FN3] ( ____________ and I jointly and severally) undertake that defendant will appear in
(e) If decedent is survived by a spouse and a parent, or parents but no issue, and there is a claim for wrongful death, check here [ ] and furnish name(s) and address(es) of parent(s) in Paragraph 5. See E PTL 5-4.4.
4. The decedent left surviving the following who would inherit his/her estate pursuant to E PTL 4-1.1 and 4-1.2:
a. [ ] Spouse (husband/wife). [ ] Divorced [Attach copy of Divorce Decree]
b. [ ] Child or children or descendants of predeceased child or children, [Must include marital, non-marital, and adopted].
c. [ ] Any issue of the decedent adopted by persons related to the decedent (DRL Section 117).
d. [ ] Mother/Father.
e. [ ] Sisters and brothers, either of whole or half blood, and issue of predeceased sisters and brothers.
f. [ ] Grandmother/Grandfather.
g. [ ] Aunts or uncles, and children of predeceased aunts and uncles (first cousins).
h. [ ] First cousins once removed (children of first cousins).
[Information is required only as to those classes of relatives who would take the property of decedent pursuant to E PTL 4-1.1. State "number" of survivors in each class. Insert "No" in all prior classes. Insert "X" in all subsequent classes].
ADM/DBN-1 (7/98) -2-
5. The decedent left surviving the following distributees, or other necessary parties, whose names, degrees of relationship, domiciles, post office addresses and citizenship are as follows:
[Note: Show clearly how each person is related to decedent. If relationship is through an ancestor who is deceased, give name, date of death, and relationship of the ancestor to the decedent. Use rider sheet if space in paragraph (5) is not sufficient. See Uniform Rules 207.16(b). If any person listed in paragraph (5) is a nonmarital person, or descended from a nonmarital person, attach a copy of the order of filiation or Schedule A. If any person listed in paragraph (5) was adopted by any persons related by blood or marriage to decedent or descended from such persons, attach Schedule B.]
5a. The following are of full age and under no disability: [If nonmarital or adopted-out person, so indicate by attaching Schedule A and/or B. If any of the distributees have died subsequent to the death of the decedent, give the name and title of the legal representative appointed for such person(s), his or her address and the court that issued such letters. If any distributee who has died, subsequent to the death of the decedent, has no legal representative, then enter the name, relationship, domicile address and citizenship of that deceased person(s) distributee(s).]
Domicile and
Name Relationship Mailing Address Citizenship
5b. The following are infants and/or persons under disability: [Attach applicable Schedule A, B, C and/or D]
Domicile and
Name Relationship Mailing Address Citizenship
ADM/DBN-1 (7/98) -3-
6. There are no other persons interested in this proceeding other than those herein mentioned.
7. There are no outstanding debts or funeral expenses, except: [Write "NONE" or state same]
WHEREFORE, your petitioner(s) respectfully pray(s) that: [Check and complete all relief requested]
() a. Process issue to all necessary parties to show cause why letters should not be issued as requested;
() b. An order be granted dispensing with service of process upon those persons named in paragraph 5 who have a right to letters prior or equal to that of the person nominated, and who are non-domiciliaries or whose names or whereabouts are unknown and cannot be ascertained;
() c. A decree award Letters of Administration d.b.n. to ____________
____________
or to such other person or persons having a prior right as may be entitled thereto, and;
() d. That the authority of the representative under the foregoing Letters be limited with respect to the prosecution or enforcement of a cause of action on behalf of the estate, as follows: the administrator(s) may not enforce a judgment or receive any funds without further order of the Surrogate.
() e. That the authority of the representative under the foregoing Letters be limited as follows:
() f. [State any other relief requested].
Dated: ________
1.
(Signature of Petitioner) 2.
(Signature of Petitioner)
______________
(Print Name)
(Print Name)
3.
______________
(Name of Corporate Petitioner)
______________
(Signature of Officer)
______________
(Print Name and Title of Officer)
ADM/DBN-1 (7/98) -4-
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF
________X
LETTERS OF ADMINISTRATION d.b.n., SCHEDULE A
Estate of NONMARITAL PERSONS
(PERSONS BORN OUT OF WEDLOCK)
a/k/a
File No. ________
Deceased.
________X
[NOTE: Nonmarital children (or their issue) who would be distributees if they (or their ancestors) were born in wedlock will not be regarded as distributees unless satisfactory proof is submitted establishing paternity]. See E PTL 4-1.2, which sets forth methods of establishing paternity.
Name of alleged distributee: ____________
Date of birth: ________ Relationship to decedent: ____________
Name of father: ____________
Name of mother: ____________
Does the birth certificate contain the father's name? Yes [ ] No [ ]
If yes, attach a copy of birth certificate.
Has an order of filiation establishing paternity been entered? Yes [ ] No [ ] If yes, attach copy of order.
Did the nonmarital person live with his or her father? Yes [ ] No [ ]
If yes, give dates and place of residence: ____________
____________
____________
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF
________X
LETTERS OF ADMINISTRATION d.b.n., SCHEDULE B
ESTATE OF ISSUE OF THE DECEDENT
WHO WERE THE SUBJECT
a/k/a OF AN ADOPTION
Deceased. File No. ____________
________X
Name of child: ____________
Relationship to decedent prior to adoption: ____________
Date of adoption: ________
Was this a step-parent adoption? (i.e., was the child adopted by the spouse of the decedent's former spouse?) Yes [ ] No [ ]
If yes, name of adoptive father or mother: ____________
If not a step-parent adoption, indicate below the biological relationship of the adoptive parent to the child:
[ ] grandparent(s)
[ ] brother or sister
[ ] aunt or uncle
[ ] first cousin
[ ] nephew or niece
Name of the adoptive parent: ____________
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF
________X
LETTERS OF ADMINISTRATION d.b.n., SCHEDULE C
ESTATE OF INFANTS
a/k/a
File No. ________
Deceased.
________X
Name: ________ Date of birth: ____________
Relationship to the decedent: ____________
With whom does the infant reside? ____________
Name of mother: ________ Is she alive? ____________
Name of father: ________ Is he alive? ____________
Does the infant have a court-appointed guardian? Yes [ ] No [ ]
If yes, name and address of guardian: ____________
____________
Name: ________ Date of birth: ____________
Relationship to the decedent: ____________
With whom does the infant reside? ____________
Name of mother: ________ Is she alive? ____________
Name of father: ________ Is he alive? ____________
Does the infant have a court-appointed guardian? Yes [ ] No [ ]
If yes, name and address of guardian: ____________
____________
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF
________X
LETTERS OF ADMINISTRATION d.b.n., SCHEDULE D
ESTATE OF PERSONS UNDER DISABILITY
OTHER THAN INFANTS
a/k/a
Deceased. File No. ____________
________X
[Use additional sheets if needed]
1. Name: ________ Relationship: ____________
Residence: ____________
With whom does this person reside? ____________
If this person is in prison, name of prison: ____________
Does this person have a court-appointed fiduciary? Yes [ ] No [ ]
If yes, give name, title and address: ____________
____________
If no, describe nature of disability: ____________
____________
If no, give name and address of relative or friend interested in his or her welfare: ____________
____________
2. Whereabouts unknown/Unknowns [persons whose addresses or names are unknown to petitioner; if known, give name and relationship to decedent]:
COMBINED VERIFICATION, OATH & DESIGNATION
[For use when petitioner is to be appointed administrator d.b.n.]
STATE OF)
COUNTY OF) ss:
The undersigned, the petitioner named in the foregoing petition, being duly sworn, says:
1. VERIFICATION: I have read the foregoing petition subscribed by me and know the contents thereof, and the same is true of my own knowledge, except as to the matters therein stated to be alleged upon information and belief, and as to those matters I believe it to be true.
2. OATH OF ADMINISTRATOR d.b.n.: I am over eighteen (18) years of age and a citizen of the United States; I will well, faithfully and honestly discharge the duties of administrator d.b.n. I am not ineligible to receive letters.
3. DESIGNATION OF CLERK FOR SERVICE OF PROCESS: I do hereby designate the Clerk of the Surrogate's Court of ________ County, and his orher successor in office, as a person on whom service of any process issuing from such Surrogate's Court may be made, in like manner and with like effect as if it were served personally upon me, whenever I cannot be found within the State of New York after due diligence used.
My domicile is:
(Street Address) (City/Town/Village) (State) (Zip Code)
______________
Signature of Petitioner
______________
(Print Name)
On ____________, ________, before me personally came
____________
to me known to be the person described in and who executed the foregoing instrument. Such person duly swore to such instrument before me and duly acknowledged that he/she executed the same.
______________
Notary Public
Commission Expires:
(Affix Notary Stamp or Seal)
Signature of Attorney: ____________
Print Name: ____________
Firm Name: ____________ Tel. No.: ________
Address of Attorney: ____________
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COMBINED CORPORATE VERIFICATION, CONSENT AND DESIGNATION
[For use when a petitioner to be appointed is a bank or trust company]
STATE OF)
COUNTY OF) ss:
The undersigned, a
(Title) of
(Name of Bank or Trust Company)
a corporation duly qualified to act in a fiduciary capacity without further security, being duly sworn, say:
1. VERIFICATION: I have read the foregoing petition subscribed by me and know the contents thereof, and the same is true of my own knowledge, except as to the matters therein stated to be alleged upon information and belief, and as to those matters I believe it to be true.
2. CONSENT: I consent to accept the appointment as Administrator d.b.n. of the decedent described in the foregoing petition and consent to act as such fiduciary.
3. DESIGNATION OF CLERK FOR SERVICE OF PROCESS: I do hereby designate the Clerk of the Surrogate's Court of ________ County, and his or her successor in office, as a person on whom service of any process issuing from such Surrogate's Court may be made, in like manner and with like effect as if it were served personally upon me, whenever I cannot be found within the State of New York after due diligence used.
______________
(Name of Corporate Petitioner)
______________
(Signature of Officer)
______________
(Print Name and Title of Officer)
On the ________, ________, before me personally came ____________
to me known, who duly swore to the foregoing instrument and who did say that he/she resides at ____________
________ and that he/she is a ____________
of ________ the corporation/national banking association described in and which executed such instrument, and the he/she signed his/her name thereto by order of the Board of Directors of the corporation.
______________
Notary Public
Commission Expires:
(Affix Notary Stamp or Seal)
Signature of Attorney: ____________
Print Name: ____________
Firm Name: ____________ Tel. No.: ________
Address of Attorney: ____________
ADM/DBN-1 (7/98) -6-
