PROBATE COURT OF STARK COUNTY, OHIO DIXIE PARK, JUDGE ESTATE OF CASE NO. , DECEASED FIDUCIARY'S ACCOUNT [R.C. 2109.30, 2109.301 and 2109.32] [Executors and Administrators] The fiduciary offers the account given below and on the attached itemized statement of receipts and disbursements. The fiduciary states that the account is correct, and asks that it be approved and settled. [Check one of the following] This is a partial account. A statement of the assets remaining in the fiduciary's hands is attached. This is a final account. A statement of the assets remaining in the fiduciary's hands for distribution to the beneficiaries is attached. This is an account of distribution and fiduciary asks to be discharged upon its approval and settlement. This is a final and distributive account and the fiduciary asks to be discharged upon its approval and settlement. This is a supplemental final account. [Complete if this is a partial account, or if one or more accounts have previously been filed in the estate] The period of this account is from to [Complete if applicable] Accounts previously filed in the estate, the accounting periods, and the fiduciary and attorney fees paid for each period, are as follows: Date Filed Accounting Period $ Fiduciary Fees Paid Attorney Fees Paid $ Note: 2117.06(K) states: "The distributee may be liable to the estate up to the value of the distribution and may be required to return all or any part of the value of the distribution if a valid claim is subsequently made against the estate within the time permitted under this section. " 2109.32(C) states: "The rights of any person with a pecuniary interest in the estate are not barred by approval of an account pursuant to division (A) and (B) of this section. These rights may be barred following a hearing on the account pursuant to section 2109.33 of the Revised Code. " 13.0 - FIDUCIARY'S ACCOUNT 12/01 /2002 American LegalNet, Inc. www.FormsWorkFlow.com Case No. This account is recapitulated as follows: RECEIPTS Personal property not sold ................................................................ ...................................................... $ Proceeds from sale of personal property Real property not sold ......................................................................... ........................................................... Proceeds from sale of real property Income ............................................................................................. .................................................................................... ..................................................................................... .............................$ ................................ $ Other receipts Total receipts DISBURSEMENTS Fiduciary fees this accounting period Attorney fees this accounting period Other administration costs and expenses ................................. Debts and claims against estate Ohio and federal estate taxes ..................................... ....................................... ............................... ................................... $ Personal property distributed in kind Real property transferred .............................................. ..................................................... Other distributions to beneficiaries Other disbursements Total disbursements .................................................. BALANCE REMAINING IN FIDUCIARY'S HANDS ...........................................................$ Fiduciary Date Attorney Attorney Registration No. ENTRY SETTING HEARING The Court sets hearing the above account. at o'clock M., as the date and time for Date Dixie Park - Probate Judge American LegalNet, Inc. www.FormsWorkFlow.com