IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF DESCHUTES In the Matter of Conservatorship of: Enter Name of Protected Person Birth Date of Protected Person ) ) ) ) ) ) Case No. FUNDS Pursuant to ORS 125.475, the undersigned reports to the Court as follows: 1.My name is: 2.My residence address and telephone number are: 3.The name (if applicable), and address of the place where the protected person now resides is: 4.A brie 5.Funds held in restricted accounts total value $6.Name and address of Institution where restricted funds are held: ENCLOSED ARE COPIES OF THE BANK STATEMENTS WITHIN 30 DAYS OF THE ENDING DATE OF THIS ACCOUNTING AND CONFIRMING THE BALANCE ON HAND 7.I HEREBY CERTIFY THAT SINCE MY LAST REPORT:(all questions must be completed, if not applicable, so state) A. I have been convicted of the following crimes (not including traffic infractions): B. I have filed for or received protection from creditors under the Federal Bankruptcy code: No Yes If yes, Bankruptcy Case No. American LegalNet, Inc. www.FormsWorkFlow.com C. I have had a professional or occupational license revoked or suspended: No Yes Explanation: No Yes 8.Request for Release of Restricted Assets (if applicable) The conservator herewith petitions the court for the release of the amount of $ , from restricted conservatorship assets for the following purpose: 9.I HEREBY CERTIFY THAT A TRUE COPY OF THIS REPORT HAS BEEN GIVEN OR MAILED TO THE PROTECTEDPERSON OR MINOR (IF 14 YEARS OF AGE OR OLDER) AND ANY OTHER PERSON WHO IS ENTITLED TO OR HAS REQUESTED NOTICE AS FOLLOWS: PERSON: BY PERSONAL SERVICE OR MAIL AT:DATE SERVED/MAILED: I HEREBY DECLARE THAT THE ABOVE STATEMENT IS TRUE TO THE BEST OF MY KNOWLEDGE AND BELIEF, AND THAT I UNDERSTAND IT IS MADE FOR USE AS EVIDENCE IN COURT AND IS SUBJECT TO PENALTY FOR PERJURY. DATED: American LegalNet, Inc. www.FormsWorkFlow.com