Superior Court of the District of Columbia Probate Division In re: _________________________ _____ GDN _____ _____ TRP _____ _____ CON _____ _____ INT _____ _____ IDD _____ INVENTORY REPORT The report of _________________________________________________, Guardian, Conservator, Committee, Trustee, Receiver (strike all except one) who qualified as such on the ________ day of ___________________, ______, respectfully shows that the estate consists of the following: REAL ESTATE Location and Description Assessed Value COLUMN TOTALS $ Encumbrances (Mortgages) $ Market Value $ BANK DEPOSITS AND OTHER MONEY Account No. (last 4 digits only) Amount Deposited In (Name of Depository) In the Name of (Registration on Account) $ TOTAL Jan. 2010 $ 1 American LegalNet, Inc. www.FormsWorkFlow.com NOTES SECURED BY MORTGAGE OR DEED OF TRUST ON REAL ESTATE (Do not Include Encumbrances Listed Under Real Estate Above) Location Property and Description TOTAL of Amount (Balance Due) Interest Rate Maker’s Name and Name of Present Payor Maturity (Month, Day, and Year) Terms of Repayment $ STOCKS (List each certificate separately) Class (common, preferred) Shares Name of Company Certificate Nos. TOTALS Jan. 2010 Issue Date Carrying Value $ Fair Market Value $ 2 American LegalNet, Inc. www.FormsWorkFlow.com BONDS Issued by (Name of Company or Agency) Certificate Nos. (last 4 digits only) Purchase or Maturity Date Interest Rate Face Value Carrying Value Fair Market Value $ $ $ TOTALS $ $ $ OTHER SECURITIES (List each separately and in detail) The foregoing securities are kept or deposited at ____________________________ (Explain fully) ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ in the name of _______________________________________________________ Jan. 2010 3 American LegalNet, Inc. www.FormsWorkFlow.com AUTOMOBILES, JEWELRY, HOUSEHOLD EFFECTS AND ALL OTHER PERSONAL ASSETS Attached additional page(s) if necessary The penalty of my undertaking is $_______________ It was filed on the _______ day of _______________, 20___. The surety is ___________________________________________________ When the undertaking was filed, the value of the estate was $____________ VERIFICATION I ________________________________, being first duly sworn, on oath, depose and say that I have read the foregoing inventory report by me subscribed and that the facts therein stated are true to the best of my knowledge, information and belief. _________________________________ Signature _________________________________ Typed Name _________________________________ Address (Actual address/not Post Office) _________________________________ _________________________________ Telephone Number _________________________________ E-mail address (Optional) Subscribed and sworn to before me this _______ day of ________________, 20___. _________________________________ Notary Public/Deputy Jan. 2010 4 American LegalNet, Inc. www.FormsWorkFlow.com