IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI - PROBATE DIVISION AT IN THE ESTATE OF ESTATE NUMBER , Protectee. Deceased. SETTLEMENT (Annual) (Final) The undersigned fiduciary of the above captioned estate submits the following as a just and true account for the period from to and including . ASSETS PER INVENTORY OR LAST SETTLEMENT 1. Furniture, household goods, wearing apparel. $ 2. Corporation stocks. 3. Mortgages, bonds, notes. 4. Cash, Bank and Savings and Loan Accounts. Insurance Policies 5. All other property. TOTAL $ Attached hereto on separate sheets is a detailed account describing each transaction and showing the date funds or other assets were received or paid out. Also attached hereto is a summary of the ending balances of personal property as of the date last above written. (See Reverse Side for Instructions) Page 1 of 3 2001 © American LegalNet, Inc. INSTRUCTIONS RE SETTLEMENT The detailed account to be attached to the settlement form should report transactions in the following form: YEAR Mo./Day DETAILS OF TRANSACTION VOUCHER NO. REC’D./ DEBIT $ PAID OUT/ CREDIT $ As to decedent’s estates, section 473.543 provides: “Each settlement filed by a personal representative shall state the period for which it is made and, among other things, shall contain a just and true account of all moneys by him collected, the date when collected, from whom collected and on what account collected, whether on claims charged in the inventory or for property and interest collected on each claim and also, the amount and date of each expenditure or distribution, and to whom and for what paid. Such settlement shall also show what interest has been obtained by the personal representative upon any funds in his hands, and when obtained, on what amounts, for what time and at what rate percent. Each expenditure for which a personal representative claims credit in any settlement shall be supported by vouchers executed by the person to whom the disbursement was made. Every settlement shall be signed by the personal representative.” As to protectee’s estates, section 475.270.2 provides: “Each settlement of a conservator shall conform to the requirements of section 473.543, RSMo, as to settlements in decedents’ estates.” Form 10559 Page 2 of 3 7/23/96 2001 © American LegalNet, Inc. ESTATE NUMBER ENDING BALANCES DEBIT CREDIT TOTAL BALANCE THE ABOVE BALANCE CONSISTS OF THE FOLLOWING: 1. Furniture, household goods, wearing apparel. $ 2. Corporation stocks. 3. Mortgages, bonds, notes. 4. Cash, Bank and Savings & Loan Accounts. 5. All other personal property. TOTAL $ The undersigned swears that the matters set forth above are true and correct to the best knowledge and belief of the undersigned, subject to the penalties of making a flase affidavit or declaration. . Dated: Personal Representative Conservator Address zip ATTORNEY: BAR No ADDRESS: FAX NUMBER: ( Dated: / ) TELEPHONE: ( zip E-MAIL ADDRESS: SETTLEMENT APPROVED . Judge Form 10559 ) Page 3 of 3 Commissioner 7/23/96 2001 © American LegalNet, Inc.