CIRCUIT ORPHANS' COURT FOR , MARYLANDCity/County002 Located at002 Case No. Court Address In the Matter of Name of Minor or Disabled Person FIDUCIARY'S ACCOUNT (Rule 10-708(a))I, , make this periodic final Fiduciary'sGuardian of the Property Account for the period from Date The Fiduciary Estate consists of the following assets as Inventory carried forward from last Fiduciary Account: A. REAL ESTATE B. CASH & CASH EQUIVALENTS C. PERSONAL PROPERTY D. STOCKS E. BONDS F. OTHER002 TOTAL002 to Datereported on the Fiduciary's $ $ $ $ $ $ $ The following changes in the assets of the Fiduciary Estate have occurred since the last account: (Please include real or personal property that was bought, sold, transferred, exchanged, or disposed of and any loans that were taken out on any asset in the estate. Attach additional sheets, if necessary.) A. INCOME Date Received Type of Income (e.g., pension, social security, rent, annuity, dividend, interest, refund) Source Amount $ $ $ $ $ $ $ TOTAL CC-GN-012 (Rev. 10/2017) Page 1 of 3 American LegalNet, Inc. www.FormsWorkFlow.com B. DISBURSEMENTS002 Date of Payment To Whom Paid Purpose of Payment Amount $ $ $ $ $ $ $TOTAL C. ASSETS ADDED002 Date Description of Transaction Gross Purchase Price Value at date of acquisition if other than by purchase $ $ $ $ $ $ $TOTAL D. ASSETS DELETED002 Date Description of Transaction Gross Sale Proceeds Selling Costs Carrying Value Gain or (Loss) CC-GN-012 (Rev. 10/2017) Page 2 of 3 American LegalNet, Inc. www.FormsWorkFlow.com SUMMARY $Total Income..............................................................002 $Total Disbursements...................................................002 $Total Assets Added....................................................002 $Total Assets Deleted...................................................002 $Total Changes.............................................................002 A Summary of the Fiduciary Estate to be carried forward to next account: A. REAL ESTATE003 $ B. CASH & CASH EQUIVALENTS003 $ C. PERSONAL PROPERTY003 $ D. STOCKS003 $ E. BONDS003 $ F. OTHER003 $ TOTAL $ The Fiduciary bond, if any, has been filed in this action in the amount of $ VERIFICATION: I solemnly affirm under the penalties of perjury that the contents of this document are true to the best of my knowledge, information, and belief. Signature of the Fiduciary Date Signature of the Fiduciary Date Address Address City, State, ZipTelephone City, State, Zip Telephone Name of Fiduciary's Attorney Address City, State, Zip Fax E-mail CPF ID No. CC-GN-012 (Rev. 10/2017) Page 3 of 3 American LegalNet, Inc. www.FormsWorkFlow.com