CIRCUIT COURT OF CLAY COUNTY, MISSOURI PROBATE DIVISION NO. Matter of , a disable person, now deceased. APPLICATION FOR APPROVAL OF FINAL SETTLEMENT AND PROPOSED ORDER OF DISTRIBUTION TO PERSONAL REPRESENTATIVE As Conservator of the above-named estate, I hereby state to the Court that my Protectee died on the _____ day of , 20_____, *with___ *without a will; that my final settlement has been filed; and that this estate is in a proper condition to be closed. WHEREFORE, I request that the Court approve my final settlement and authorize me to make distribution to the Personal Representative of the deceased estate in accordance with the proposed order of distribution which is attached hereto and made a part of this application. THE STATEMENTS AND REPRESENTATIONS IN THIS DOCUMENT ARE MADE UNDER OATH AND ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND THEY ARE MADE SUBJECT TO THE PENALTIES OF MAKING A FALSE AFFIDAVIT OR DECLARATION. Date_________________ Conservator *Strike if inapplicable Form 376-A Revised 3/14/2003 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com