List of Phase II Distributees

File No. STATE OF NORTH CAROLINA ► In The General Court Of Justice County Superior Court Division Before The Clerk IN THE MATTER OF THE ESTATE OF: Name Of Decedent

Decedent's Social Security Number LIST OF PHASE II DISTRIBUTEES Name And Address Of Personal Representative Or Collector By Affidavit

G.S. 28A-21-3.1 The undersigned being duly sworn or affirmed states that: 1. I am the duly authorized personal representative or collector by affidavit of the above-referenced estate. 2. There are no unsatisfied creditors. 3. There are no unsatisfied general monetary bequests. 4. All assets other than any potential Phase II payments have been distributed. 5. The names and addresses of devisees or heirs of the decedent entitled to receive Phase II payments and the percentage of the Phase II payments to be received by each are listed below. (Attach additional sheets if necessary.)

NOTE: If an heir/devisee is under the age of 18 at the time hereof, or if the heir/devisee has been declared incompetent, you must also list a person authorized by law to receive funds on behalf of a minor or incompetent. See Side Two.

Percentage Relationship to Of Payment Name Address (If Known) Decedent Entitled To Receive

Date SWORN/AFFIRMED AND SUBSCRIBED TO BEFORE ME

Date Signature Of Person Authorized To Administer Oaths Signature Of Personal Representative Or Collector

Deputy CSC Assistant CSC Clerk Of Superior Court Date My Commission Expires Notary County Where Notarized SEAL CLERK'S REVIEW AND APPROVAL I have reviewed the List of Phase II Distributees and determined that the list of distributees and their shares of potential Phase II payments are in accordance with the will of the decedent, or if there is no will, in accordance with the Intestate Succession Act. The List is accepted for filing, is approved, and the estate is closed. Date Signature Assistant CSC Clerk of Superior Court CERTIFICATION I certify that this is a true copy of the original List of Phase II Distributees on file in this office. Date Signature Deputy CSC Clerk of Superior Court SEAL Assistant CSC

Persons Authorized By Law To Receive Funds For Minor Or Incompetent. The following persons are authorized by law to receive funds on behalf of a minor or incompetent: 1. A court appointed guardian of the estate or general guardian [G. S. 35A-1251 and 1252]. 2. The parent of a minor, if: a) the minor is residing in the same household with the parent, b) the cumulative total of all distributions from the estate listed on Side One, including the current or pending distribution, does not exceed $1,500, c) the decedent died without a will, and d) the distribution is approved by the clerk of superior court [G. S. 28A-27-7]. 3. A parent, guardian, or person having custody of a child or incompetent, if the will of the decedent named on Side One authorizes such distribution [G.S. 32-26 and 27]. 4. The clerk of superior court, acting on behalf of a minor without a guardian [G. S. 28A-23-2]. 5. The clerk of superior court or public guardian, acting on behalf of an incapacitated adult for whom there is no guardian, if the amount of the current or pending distribution is $5,000 or less [G. S. 7A-111].