STATE OF VERMONT SUPERIOR COURT Unit PROBATE DIVISION Docket No.: In re Guardianship of : ADULT GUARDIAN CLOSING REPORT and DISCHARGE ORDER The following is a final report to the court concerning Name of Respondent I hereby report under oath that the following facts are true: 1. This report is filed within one year after the final accounting in this proceeding. 2. Persons entitled to money or other property have been paid in the amounts set forth in the final accounting. 3. A receipt for each payment is attached to this report together with proof of delivery or other proof as required by the Court. Based on this report, I request that I be discharged and that this proceeding be closed. Date Signature of Guardian Signed and sworn to before me: Date Signature of Notary Public Expiration Date DISCHARGE ORDER Report approved and proceeding closed. The Guardian is hereby discharged. Dated: Signed Probate Judge American LegalNet, Inc. www.FormsWorkFlow.com Form PAG152 ­ Adult Guardian Closing Report and Discharge Order (9/2014) Page 1 of 1