PROBATE COURT OF LUCAS COUNTY, OHIO JACK R. PUFFENBERGER, JUDGE IN THE MATTER OF THE: TESTAMENTARY TRUST SPECIAL NEEDS TRUST WRONGFUL DEATH TRUST OTHER OF _________________________________________________________, DECEASED, GRANTOR CASE NO. _________________________ RECEIPTS AND DISBURSEMENTS [Attach to Trustee's Account] Page _____ of _____ pages Following is an itemized statement of receipts and disbursements by the fiduciary in the administration of his/her trust. Item Voucher No. Receipts $ Disbursements $ PAGE 1 OF TRUSTEE'S ACCOUNT - FORM LCPC TST 25.5C (RECEIPTS AND DISBURSEMENTS) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. _________________________ Page _____ of _____ pages Item Voucher No. Receipts $ Disbursements $ ____________________________________ Trustee PAGE 2 OF TRUSTEE'S ACCOUNT - FORM LCPC TST 25.5C (RECEIPTS AND DISBURSEMENTS) American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. _________________________ BANK CERTIFICATE N. B. Must be executed when funds are on deposit. I HEREBY CERTIFY that the within named trustee, on the date stated below, had on deposit in The _________________________________ of ________________________________, Ohio the sum of $ ________________________ on _______________________________ to the credit of the trust of Nature of Deposit ________________________________________ Bank ________________________________________ Dated By Cashier Trustee BANK CERTIFICATE N. B. Must be executed when funds are on deposit. I HEREBY CERTIFY that the within named trustee, on the date stated below, had on deposit in The _________________________________ of ________________________________, Ohio the sum of $ ________________________ on _______________________________ to the credit of the trust of Nature of Deposit ________________________________________ Bank ________________________________________ Dated By Cashier Trustee PAGE 3 OF TRUSTEE'S ACCOUNT - FORM LCPC TST 25.5C (BANK CERTIFICATE) American LegalNet, Inc. www.FormsWorkFlow.com