IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI - PROBATE DIVISION AT IN THE ESTATE OF ESTATE NUMBER , Minor. ANNUAL STATEMENT OF AFFAIRS OF CONSERVATOR (NO FURTHER PROCESS) As conservator of the above-named minor, you must complete this report and return to the probate division on or before the date stated in the enclosed notice. Failure to fully answer each question, sign and return this reportwill result in issuance of a citation for your removal and imposition of other penalties. 1. Where is the minor presently living? (State Address): 2. Where are you (the conservator) presently living? (State Address): 3. List all restricted accounts in which the minors money or property is deposited, the name and address of the depositories and the total amount on hand in each account: 4. Other than the accounts listed in paragraph 3 above, list all other accounts in which the minors money o property is deposited, the name and address of the depositories and the total amount on hand in each account: 5. In the past 12 months have you received any other money or property for the minor? If so, statethe date received, the amount or value and the source thereof: 6. In the past 12 months have you spent any of the money described above for the minor? If so, state the amount and purpose of the expenditures: The undersigned swears that the answers set forth above are true and correct to the best knowledge and belief of the undersigned subject to the penalties of making a false affidavit or declaration. Dated: Signed: Telephone: Form 10602 7/24/96