IN THE CIRCUIT COURT OF THE STATE OF OREGON THIRD JUDICIAL DISTRICT Probate Department In the Matter of the Protective Proceeding for: _______________________________________ A Minor, Protected Person. ) ) ) ) ) Case No. CUSTODIAN’S REPORT I am the custodian of funds for the child named above, and I make the following report to the court: 1. My name, address and telephone number are: Phone: ( 2. The address where the child lives is: 3. Since my last report I have: a. Been convicted of the following crimes: b. Received protection under federal bankruptcy laws: “ yes / “ no. c. Had a job-related license revoked or suspended: “ yes / “ no. d. Had my driver’s license revoked or suspended: “ yes / “ no. ) 4. / “ none. Attached to this report is a copy of the most recent statement of each account that holds the child’s funds. 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 this _________ day of ________________________, 20__________. Custodian CUSTODIAN’S REPORT - Page 1 of 1 FC (1/1/08) American LegalNet, Inc. www.FormsWorkFlow.com