IN THE WARREN COUNTY, OHIO COMMON PLEAS COURT PROBATE DIVISION IN THE MATTER WRONGFUL DEATH TRUST TESTAMENTARY TRUST SPECIAL NEEDS TRUST OTHER OF: ________________________________________________________________________, Deceased, Grantor for the Benefit of: _____________________________________________________________________________ CASE NO. _______________________ TRUST BENEFICIARIES The following are beneficiaries of the trust: ___________________________________________________________________________________________ Birthdate if Minor Name: ______________________________________ Income Beneficiary Address: ______________________________________ Remainder Beneficiary ______________________ ______________________________________ ___________________________________________________________________________________________ Birthdate if Minor Name: ______________________________________ Income Beneficiary Address: ______________________________________ Remainder Beneficiary ______________________ ______________________________________ ___________________________________________________________________________________________ Birthdate if Minor Name: ______________________________________ Income Beneficiary Address: ______________________________________ Remainder Beneficiary ______________________ ______________________________________ ___________________________________________________________________________________________ Birthdate if Minor Name: ______________________________________ Income Beneficiary Address: ______________________________________ Remainder Beneficiary ______________________ ______________________________________ ___________________________________________________________________________________________ Birthdate if Minor Name: ______________________________________ Income Beneficiary Address: ______________________________________ Remainder Beneficiary ______________________ ______________________________________ ___________________________________________________________________________________________ (Check whichever of the following is applicable) This will contains a charitable trust or a bequest or devise to a charitable trust, subject to R.C. 109.23 and 109.41. The will is not subject to R.C. 109.23 and 109.41, relating to charitable trusts. ________________________________________ Date WCPC Form 50.1 Eff. 04/04/11 ___________________________________________ Applicant (or give other title) ___________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com