STATE OF VERMONT SUPERIOR COURT Unit In re Guardianship of : PROBATE DIVISION Docket No.: STATEMENT OF RESPONDENT'S ASSETS and INCOME ASSETS Assets include real estate, investment accounts, bank accounts, vehicles and any other assets of significant value. List only those assets that are in Respondent's sole name. Description of Asset Approx. Value Description of Asset Approx. Value TOTAL VALUE INCOME Description of Income Source (include benefits and pensions) Amount per month TOTAL Include more sheets if necessary Date Signature of Petitioner Printed Name Statement of Assets and Income: Sheet ___ of ____. PG72 � Statement of Respondent's Assets & Income (09/2014) American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 1