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

Current through Register Vol. 46, No. 28, July
					 10, 2024
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