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 WD-3 - Account
Form WD-3
(Account)
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF ________
________x
In the Matter of the Application of
________ as Administrat of the
Goods, Chattels and Credits which were of
ACCOUNT
________
File No.________
deceased,
For leave to compromise a certain cause of action for wrongful death of the decedent and to render and have judicially settled an account of the proceedings as such
Administrat________.
________x
TO THE SURROGATE'S COURT:
1. I ________ do render the following account of my proceedings as administrat ________ of the goods, chattels and credits which were of ________, deceased, consisting of a claim against ________, who is insured by ________ Insurance Company, for wrongful death arising on or about ________, 19 ________, as the result of an automobile accident involving the decedent and ________.
2. Letters of Administration of the goods, chattels and credits of the decedent were issued to me on ________, 19________, said letters being limited to the prosecution only, and not for the collection of any proceeds of, any action or claim for wrongful death. Simultaneously herewith, leave is being asked to compromise the claim for wrongful death of the decedent for the sum of $ ________
3. There is submitted with this account my petition as administrat ________; an affidavit by ________, Esq., attorney for the petitioner herein; a copy of the paid funeral bill; and waivers of the necessary parties.
4. In view of the facts and circumstances, it is my opinion that a satisfactory result has been achieved through the efforts of my attorneys, and they are requesting disbursements in the sum of $ ________ and that they receive thereafter a fee of ________ % of the net proceeds.
5. The funeral bill in the sum of $ ________ has been paid through no-fault insurance.
6. There are no outstanding hospital bills or doctors' bills.
7. The only property coming into my hands is by reason of the compromise of the claim against the Insurance Company in the sum of $ ________
8. The decedent left surviving no other next of kin except ________, his/her widow/widower, and and ________, his/her children. All of the above persons are entitled to share in the proceeds of the compromise.
(NOTE: WHERE THERE ARE NO DISTRIBUTEES UNDER A DISABILITY, THE RENDERING OF AN ACCOUNT IS USUALLY NOT REQUIRED.)
(I) [FN3] ( ____________ and I jointly and severally) undertake that defendant will appear in
9. There are no other claims or creditors of the estate that have been presented to or have come into my hands or knowledge except for the following:
a) The Commissioner of Social Services has submitted a claim of $ ________ for public assistance rendered to decedent and his/her family for the years ________ This claim was rejected.
b) ________ has submitted a claim for $ ________ based on ________ This claim was rejected.
c) Decedent's father/mother, ________, has sought a share of the recovery based on an alleged pecuniary loss. This claim was rejected.
10. The following are the only persons interested in this proceeding:
Name Relationship Date of Birth
[List names of distributees, etc.]
New York City Possible
Department of Social Creditor -
Services
New York State Possible
Tax Commission Creditor -
________, Esqs. Attorneys -
Defendant -
Defendant's
Insurance Company Insurance -
Company
11. I charge myself as follows with the amount to be received on compromise of the claim for wrongful death against ________ Insurance Company: $ ________
12. I credit myself as follows:
a) With the amount to be paid to ________, Esqs., attorneys, including disbursements: $ ________
b) With the amount to be paid to ________, widow/widower and distributee:
(________ %) $ ________
c) With the amount to be paid to the guardian of the person and property of ________, infant, jointly with the Guardianship Clerk of the court ( ________ %) : $ ________
d) With the amount to be paid to ________, son/daughter ( ________ %): $ ________
Total: $ ________
Leaving no balance
Dated: ________
______________
Administrat
STATE OF NEW YORK)
) ss.:
COUNTY OF ________)
________ being duly sworn, deposes and says:
That I am the administrat ________ /accountant in the above estate, having been duly appointed by a decree of this Court.
The foregoing account of proceedings contains to the best of my knowledge and belief a true and complete statement of my receipts and disbursements in the estate of ________ of all monies and other property belonging to the estate or fund which have come into my hands or which have been received by any person or persons by my order or authority for use since my appointment, and a full and true statement of account of the manner in which I have disposed of same and all property remaining in my hands at the present time, and a full and true account of the nature of each and every transaction made by me since my appointment.
I do not know of any error or omission in said account to the prejudice of any person interested in said estate or fund.
________
Sworn to before me this
________ day of ________, 19________
______________
Notary Public
