PROBATE COURT OF SHELBY COUNTY, OHIO TRUST OF FOR THE BENEFIT OF CASE NO. TRUST BENEFICIARIES The following are beneficiaries of the trust: Name Residence Address I = Income Beneficiary R= Remainder Beneficiary Birthdate of Minor [Check whichever of the following is applicable] [ [ The Will contains a charitable trust or a bequest or devise to a charitable trust, subject to Revised Code Section ] 109.23 and 109.41. The Will is not subject to Revised Code Sections 109.23 and 109.41, relating to charitable trusts. ] Date Applicant (or give other title) H.C. FORM 24.0 - TRUST BENEFICIARIES American LegalNet, Inc. www.FormsWorkFlow.com 02/10/03