Annual Statement of Cash Receipts Guardianship of:__________________ Case Number:_____________ For the year of 20_____. Check or Cash Amount Source of Funds (e.g. checking acct.) Date Received Incapacitated Person's Signature Guardian Signature: ____________________________ Date: _____________ ______________________________________________________________________________________________________ Annual Statement of Cash Receipts - Page 1 or 1 SPO GDN 02.0240 (01/2008) American LegalNet, Inc. www.FormsWorkFlow.com