_____Mercer___________________
COUNTY SURROGATE COURT

IN THE MATTER OF THE ESTATE OF

___(Decedent’s name)_____, DECEASED

KNOW ALL MEN BY THESE PRESENTS, THAT I,


(Name and address of beneficiary)

of the Township of                     County of                    State of                 
hereinafter known as the Obligor, am held and firmly bound unto 
    (Name and Address of Executor)
    (Executor of name of estate)


                                                                hereinafter known as the Obligee
in the sum     (Amount Received)                         lawful money of the United
States of America, to be paid to the Obligee or to Obligee’s Attorney, Obligee’s successors in office or assigns; for which payment well and truly to be made I bind myself, my heirs, executors and administrators firmly by these presents. 
    THE CONDITION OF THE ABOVE OBLIGATION is such, that whereas, the Obligor has received from the Obligee

(Description of amount received i.e. cash, real estate, stocks, etc.)


    AND IN CONSIDERATION THEREFOR, the Obligor has released and forever discharged, and by these presents, does release and forever discharge the Obligee from all claims and demands whatsoever on account of or in respect to the estate of the said deceased, and of Obligor’s interest therein;

If the Obligor is a legatee and any part of the whole of such legacy shall at any time hereafter appear to be wanting to discharge any debt or debts, legacy or legacies, which the said executor or administrator may not have other assets to pay, the Obligor will return said legacy or such part thereof as may be necessary for the payment of the said debts, or for the payment of a proportional part of the said legacies; or

If the Obligor is a distributee and any debt or debts, truly owing by the intestate, shall be afterwards sued for and recovered or otherwise duly made to appear, and which there shall be no other assets to pay, Obligor shall refund and pay back to the administrator his ratable part of such debt or debts, out of the part and share so allotted to him;

Then the above obligation to be void, or else to be and remain in full force and virtue.

If more than one person executes the within instruments, then words used in the singular shall be considered to include the plural, and wherever herein any particular gender is used it shall be inclusive of the masculine, feminine and neuter gender, where the text so requires.

SIGNED, SEALED AND DELIVERED 
IN THE PRESENCE OF


                                                            ______(Beneficiary)______________________
______(Witness)___________________________


STATE OF 
COUNTY OF 

    BE IT REMEMBERED, That on this day of , 20 before me, the subscriber, a of the State of personally appeared who, I am satisfied, is the person
in the foregoing instrument named, and thereupon acknowledged that he/she signed, sealed and delivered the same as his/her act and deed, for the uses and purposes therein expressed.

                         ________________________________________ Notary Public (seal)