CIRCUIT COURT OF CLAY COUNTY, MISSOURI PROBATE DIVISION No Matter of , disabled person, now deceased. APPLICATION FOR APPROVAL OF FINAL SETTLEMENT AND PROPOSED ORDER OF DISTRIBUTION TO HEIRS AT LAW As Conservator of the above-named estate, I hereby state to the Court that my Protectee died on the ________ day of _______________________, 20_______, without leaving a Will and on order of this Court all of the debts and expenses have been paid; that this estate is in a proper condition to be closed; and that my Final Settlement has been filed. WHEREFORE, I request that the Court approve my final settlement and authorize me to make distribution to the persons named and in the proportions set forth, in 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 Form 368-A Revised 3/14/2003 Page 1 of 1 American LegalNet, Inc. www.FormsWorkFlow.com