STATE OF SOUTH CAROLINA ) ) ) ) ) ) COUNTY OF: IN THE MATTER OF: IN THE PROBATE COURT CONSERVATORSHIP ANNUAL ACCOUNTING CASE NUMBER: Conservator: 1. a. b. 2. This is a full and true statement of account in the above matter, which protected person resides at , covering the period from the day of to the day of , 20 . I have on file a surety bond approved by the Court in a penal sum of $ Company as surety. , 20 with the Recapitulation of Accounts Beginning balance of cash $ Plus money received for all sources (item 3) +$ TOTAL $ Less Total money spent (item 4) -$ TOTAL VALUE OF ESTATE $ The Conservator represents that this account contains a correct statement of all receipts and disbursements and that its contents are true to the best knowledge and belief of the Conservator. SWORN to before me this day of , 20 Notary Public for South Carolina My Commission Expires: Form #561PC (2/2004) 62-5-419 Signature: Name: Address: Telephone (O): (H): Page 1 of 3 American LegalNet, Inc. www.USCourtForms.com Attach Bank or Brokerage Statements 3. MONEY RECEIVED Date RECEIVED FROM (List each source separately) Example: First Bank = Check #11111 Amount $ $ $ $ $ $ (Attach additional pages, if necessary) TOTAL brought forward from attached pages $ TOTAL AMOUNT RECEIVED $ (Enter under recapitulation, page 1, item #2) 4. MONEY SPENT Date To Whom Paid and Purpose Amount $ $ $ $ $ $ (Attach additional pages, if necessary) SUB-TOTAL brought forward from attached pages $ TOTAL AMOUNT SPENT $ (Enter total on Recapitulation, page 1, item #2) Form #561PC (2/2004) Page 2 of 3 American LegalNet, Inc. www.USCourtForms.com 5. CERTIFICATION OF BALANCE ON DEPOSIT: NAME AND ADDRESS OF INSTITUTION: Account Type (i.e., Checking, Savings): Balance on deposit* *Including interest of $ $ paid during the period covered by the accounting. I CERTIFY THAT on the day of , 20 , the last day of the period covered by this accounting, there was on deposit in this institution to the credit of this Fiduciary the following . balance:$ SIGNATURE AND TITLE OF CERTIFYING BANK CERTIFICATION OF INVESTMENTS (to be executed by the Clerk of Court, a bank official, an authorized official of an insurance or investment company, or an authorized official or agent of the corporate surety on fiduciary bond): Kind of Bond or Security Interest Rate Date of Purchase Face Value TOTAL COST Cost $ I CERTIFY that the securities listed herein were exhibited to me by the Fiduciary as being the property of the protected person and in the custody and control of the Fiduciary. Date Form #561PC (2/2004) SIGNATURE AND TITLE OF CERTIFYING OFFICIAL Page 3 of 3 American LegalNet, Inc. www.USCourtForms.com