IN THE PROBATE DIVISION, CIRCUIT COURT, ST. LOUIS COUNTY, MISSOURI In the matter of No. Respondent/Minor EXHIBIT A - FINANCIAL STATEMENT (Assets of the respondent or minor only) PERSONAL PROPERTY: Checking Accounts 226 Name of Bank and Last 4 Digits of Account Numbers $ $ $ Savings Accounts 226 Name of Bank and Last 4 Digits of Account Numbers $ $ $ Certificates of Deposit 226 Name of Bank and Last 4 Digits of Account Numbers $ $ $ Stocks and Bonds $ Vehicles 226 Year, Make and Model $ $ $ Other $ $ $ TOTAL PERSONAL PROPERTY $ CCPR014-W Rev. 08-2018 1 American LegalNet, Inc. www.FormsWorkFlow.com MONTHLY INCOME: Social Security Payee $ Supplemental Security Income Payee $ Veterans Administration Benefits $ Pension Source $ Interest $ Dividends $ Other Source $ TOTAL MONTHLY INCOME $ REAL PROPERTY 226 MISSOURI AND OUT OF STATE: (List location by address and value) $ $ $ Date Petitioner CCPR014-W Rev. 08-2018 2 American LegalNet, Inc. www.FormsWorkFlow.com