Form JA-2 - Receipt and release
SURROGATE'S COURT OF THE STATE OF NEW YORK
COUNTY OF
________X
ACCOUNTING BY
as the RECEIPT AND RELEASE
of the ESTATE OF
a/k/a
Deceased. File No. ________
________X
The undersigned, being of full age, sound mind and under no disability, and entitled to share in the estate of the above-named decedent as a [check one] [ ] legatee under a will, [ ] distributee of an intestate share, [ ] trust beneficiary, [ ] creditor of the estate, [ ] other [specify] ____________
(a) Acknowledges that each fiduciary named above has fully and satisfactorily accounted for all assets of the estate;
(b) Approves the written account verified on ________, 19________, as submitted to the undersigned;
[Delete paragraphs (a) and (b) if the undersigned is not interested in or affected by the amount of the residuary estate or trust, or if payment is being made pursuant to a decree of the court.]
(c) Acknowledges receipt of money paid or property transferred or delivered as follows:
Money (cash or check): $________
the following property: valued at $________
The foregoing payment and/or transfer is in full payment or distribution of:
[ ] a legacy under Paragraph/Article ________ of the will or trust:
[ ] a claim against the estate;
[ ] the amount directed to be paid by a decree of this court dated:
[ ] other [specify]:
(d) Releases and discharges each fiduciary named above from all liability to the undersigned for any and all matters relating to or derived from the administration of the estate; waives the issuance and service of a citation to attend any and all proceedings for the judicial settlement of the account; and authorizes the Surrogate to make and enter a decree settling the account and fully releasing and discharging each fiduciary named above as to all matters embraced therein.
Dated: ________
(Signature)
(Corporate Name)
_____________
(Print Name)
_____________
(Signature of Officer)
JA-2 (12/96)
STATE OF NEW YORK )
COUNTY OF ) ss.:
On ________, 19 ________, before me personally appeared
[INDIVIDUAL]
[ ] ________ to me known and known to me to be the person described in and who executed the foregoing receipt and release and duly acknowledge the execution thereof.
[CORPORATION]
[ ] ________ 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 that he/she signed his/her name thereto by order of the Board of Directors of the corporation.
______________
Notary Public
Commission Expires:
(Affix Notary Stamp of Seal)
Name of Attorney: ____________ Tel. No.: ________
Address of Attorney: ____________
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