Financial Report Trust PC-443 REV. 2/16 R E C E IVE D : CONNECTI CUT PROBATE COURTS R E C O R DE D : Instructions: 1) A trustee may use this financial report instead of filing an account for a trust unless: (a) the court has ordered the trustee to file an account; or (b) an account is required by the Probate Court Rules of Procedure, section 38.1 2) Type or print the form in ink. 3) Attach supporting schedules if necessary to provide additional details or explanatory notes. 4) The trustee shall send a copy of this financial report to each party and attorney. 5) For additional information, see the Probate Court Rules of Procedure, sections 37.2 and 37.4. Probate Court Name District Number Estate of Trust Under Article of Will for the Benefit of Trustee (List name, address and telephone number of each trustee.) EACH TRUSTEE WHO SIGNS THIS FINANCIAL REPORT REPRESENTS UNDER PENALTY OF FALSE STATEMENT THAT: 1) The financial report is being filed for the following reason: Periodic financial report. C.G.S. section 45a-177 Final financial report 2) All taxes, expenses of administration and claims against the estate are shown below and have been paid. This financial report covers the period (Month, Day, Year): From To 3) The trustee has retained all supporting records for this financial report as required by the Probate Court Rules of Procedure, section 36.13, and the records are available for review upon request. 4) The following is a true and complete summary of the assets of the trust and the trustee's receipts, payments and distributions. Financial Report Trust American LegalNet, Inc. www.FormsWorkFlow.com PC-443 PAGE 1/4 Financial Report Trust PC-443 REV. 2/16 CONNECTI CUT PROBATE COURTS R E C O R DE D : Assets and Income Received Total amount reported on the inventory of the trust or on hand at the end of the accounting period in most recent financial report or account Total amount of additional assets received Income received: Interest Dividends Annuities Rent Other (Specify and attach second sheet if necessary.) Net amount of gain (or loss) on the sale of assets If real property has been sold, attach copy of settlement statement from closing. Total $ $ $ $ $ $ $ $ $ Administration Expenses Paid Administration Expenses: Fiduciary fees Fiduciary disbursements Attorney's fees Attorney's disbursements Accounting expenses Probate court fees and expenses Probate bond premium Publication of notices Taxes: Property Tax Income Tax Other Expenses (Specify and attach second sheet if necessary.) Total $ $ $ $ $ $ $ $ $ $ $ $ Distributions to or for the Benefit of Beneficiaries Complete the following section for distributions made during the accounting period. Except as provided under the Probate Court Rules of Procedure, section 37.4(b), distributions must be shown at fair market value. Attach second sheet if necessary. Total Amount of Distributions to Beneficiaries During Accounting Period Name of Beneficiary Specify section of will providing for distribution If distribution was discretionary, provide a brief explanation of the basis for the distribution (e.g., health, support, education, etc.) Fair Market Value $ $ $ Subtotal $ Financial Report Trust American LegalNet, Inc. www.FormsWorkFlow.com PC-443 PAGE 2/4 Financial Report Trust PC-443 REV. 2/16 CONNECTI CUT PROBATE COURTS R E C O R DE D : Name of Beneficiary Specify section of will providing for distribution If distribution was discretionary, provide a brief explanation of the basis for the distribution (e.g., health, support, education, etc.) Fair Market Value $ $ $ Subtotal $ $ $ $ Subtotal $ Total $ Total Assets on Hand at the End of the Accounting Period Enter the total amount on hand at the end of the accounting period at fair market value below, except that assets that are difficult to value may be reported at the fiduciary acquisition value. If this is a final financial report for the trust, a proposed distribution must be submitted. See Form PC-443A, Schedule A: Proposed Distribution/ Final Financial Report/Trust. Total Assets On Hand $ EACH TRUSTEE REQUESTS: (1) approval of this financial report; (2) approval of any proposed distribution on Form PC-443A, Schedule A: Proposed Distribution/Final Financial Report/Trust, if applicable; and (3) release from liability with respect to all items shown on this financial report. The representations contained in this financial report are made under the penalty of false statement. Signature of Trustee Type or Print Name Date Signature of Trustee Type or Print Name Date Financial Report Trust American LegalNet, Inc. www.FormsWorkFlow.com PC-443 PAGE 3/4 Financial Report Trust PC-443 REV. 2/16 CONNECTI CUT PROBATE COURTS R E C O R DE D : Certification I certify that a copy of this financial report, including PC-443A, Schedule A: Proposed Distribution/Final Financial Report/Trust, if applicable, was sent to each of the following persons: Name and Address Signature of fiduciary or attorney _________________________________________________________________ Type or Print Name: ______________________________________________________________________________________________________ Date: ______________________________________________________________________________________________________________________ Financial Report Trust American LegalNet, Inc. www.FormsWorkFlow.com PC-443 PAGE 4/4