**Must be submitted on green paper CIRCUIT COURT OF CLAY COUNTY, MISSOURI PROBATE DIVISION No. , Deceased Matter of Personal Representative________________________________________ STATEMENT OF ACCOUNT Personal Representative – Unsupervised Administration The following statement of account is a just and true accounting from _____________20___ to and including ___________, 20______. SETTLEMENT ASSETS PER INVENTORY 1. Furniture, household goods, wearing apparel________________ ___________ ___ 2. Corporation stocks_____________________________________ ___________ ___ 3. Mortgages, bonds, notes________________________________ ___________ ___ 4. Cash, Bank and Savings & Loan Accounts__________________ ___________ ___ Insurance Policies____________________________________ ___________ ___ 5. All other personal property_____________________________ ___________ ___ TOTAL Year Mo. Day Form 606 D I Revised 1/11/2007 DETAILS OF TRANSACTION Voucher No. Received/Credit Dollars Cts Paid Out/Debit Dollars Cts. Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com Year Mo. Day Form 606 D I Revised 1/11/2007 DETAILS OF TRANSACTION Voucher No. Received/Credit Dollars Cts Paid Out/Debit Dollars Cts. Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com Year Mo. Day Voucher No. DETAILS OF TRANSACTION Received/Credit Dollars Cts Paid Out/Debit Dollars Cts. Totals Balance THE ABOVE BALANCE CONSISTS OF THE FOLLOWING: 1. Furniture, household goods, wearing apparel________________ ___________ ___ 2. Corporation stocks_____________________________________ ___________ ___ 3. Mortgages, bonds, notes________________________________ ___________ ___ 4. Cash, Bank and Savings & Loan Accounts__________________ ___________ ___ Insurance Policies____________________________________ ___________ ___ 5. All other personal property_____________________________ ___________ ___ TOTAL The undersigned Personal Representative ________ state ________: That the foregoing settlement contains a just and true accounting, omitting vouchers, of all receipts and disbursements of the probate assets coming into the possession of the Personal Representative; That all claims, expenses of administration and taxes have been paid, in full, except the following, together with an explanation of why said items have not been fully paid: That the Personal Representative_____ will distribute the remaining probate assets in accordance with the following schedule unless objection to the proposed distribution is filed in Court with twenty (20) days after the filing of this Statement of Account: SCHEDULE OF PROPOSED DISTRIBUTION DISTRIBUTEE Form 606 D I Revised 1/11/2007 RELATIONSHIP OR ARTICLES OF WILL FRACTIONAL INTEREST PERSONAL PROPERTY TO WHICH EACH DISTRIBUTEE IS ENTITLED Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com Real Property described in the Inventory filed with the Court RELATIONSHIP OR ARTICLES OF WILL HEIR or DEVISEE INTEREST The undersigned Personal Representative _____ further state_____: That Notice of Grant of Letters, as required by Sec. 473.033 RSMo., including a paragraph stating that Letters authorizing independent administration, in the form required by Sec. 473.783 RSMo., was duly given, and the first publication of such Notice occurred more than six (6) months before the filing of this Statement of Account. That Notice was given in the manner provided by Sec. 472.100.2 (2) RSMo., at least twenty-nine (29) days prior to the filing of the Statement of Account which notice stated that: (a) The Personal Representative would file the Statement of Account on the date certain or as continued by the Court; (b) Objections to the Schedule of Proposed Distribution shall be filed with the Court within twenty (20) days after the filing of the Statement of Account and; (c) The notice was published once a week for four consecutive weeks, the last publication at least seven days prior to the date specified therein for filing of the Statement of Account. That copies of the Statement of Account, copies of the original and any supplementary and corrected Inventories and all Settlements filed in the Court and, a notice were mailed together by ordinary mail to each interested party, such notice stating that the Statement of Account would be filed in the Court on a date stated in the notice and, that if no objections were filed in the Court within twenty (20) days after the filing of the Statement of Account, the Personal Representative would distribute in accordance with the Schedule of Proposed Distribution contained in the Statement of Account. That the mailed Notice further stated that if no proceeding is commenced in the Court within 6 months after filing of the Statement of Account, the Personal Representative would be discharged from further claim or demand by any interested party. 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. Signature Personal Representative Signature: Co-Personal Representative Address: Address: Phone Phone: Attorney: Bar Number: Address Phone Number: Form 606 D I Revised 1/11/2007 Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com