(Copy Receipt) (Clerk’s Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In Re The Trust for: CASE NO. _______________________ ORDER APPROVING TRUST _______________________________ An Incapacitated or Disabled Person (CLERK’S ACTION REQUIRED) CLERK’S INFORMATION SUMMARY Due Date for Receipt(s) for Blocked Account: _______________________________________ Due Date for Bond: ____________________________________________________________ Due Date for 1st Annual Account: _________________________________________________ Due Date for Inventory: _________________________________________________________ Due Date for Statement of Need & Projected Disbursements: ___________________________ Name, Address and Telephone for Trustee/Attorney: __________________________________ This matter came before the Court on a petition to approve a trust characterized as a: Trust Resulting from the Settlement of a claim on behalf of a minor or incapacitated person in accord with SPR 98.16 w. Special Needs Trust on behalf of a disabled person. The beneficiary of the trust: is the subject of a guardianship. The guardian is _______________________________. #-100-ORDER APPROVING TRUST PAGE 1 OF 3 Revised 4/07 American LegalNet, Inc. www.FormsWorkflow.com is not the subject of a guardianship. The trust document was drafted by ________________________________________________. This person was selected by: the Court ______________________________________________________________________ A Guardian ad Litem for the beneficiary: was not appointed because: the trust was drafted by independent counsel per court Order the beneficiary is competent and eligible for a special needs trust due to physical disability only. was appointed and is ______________________________________________________. The initial trustee(s) appear(s) to be free of any conflicts that might impair their independent judgment in the administration of the trust. The Court finds that the beneficiary is under the age of 65 years and is disabled within the criteria set forth at 42 USC 1382(c) and Social Security Act Section 1641(a)(3). He/she is qualified to be the beneficiary of such a trust, and further that the proposed Trust Agreement and the trust itself are in the best interests of the beneficiary. As such, the Trust is hereby approved and created as set forth herein. Now therefore it is ordered: 1. The ______________________________ Trust, filed herewith is approved by the Court. 2. The trustee(s) shall file annual accountings due no later than 90 days after the anniversary of the date of this order. Notice of each accounting shall be provided to ______________________________. 3. Bond is set in the amount of $____________ and shall be approved by the Court prior to the funding of the trust, but in no event later than ____________________, 20______. The following accounts shall be blocked subject to the disbursement only by court order. __________________________________________________________________ ___________________________________________________________________________ A receipt for blocked account shall be filed by _________________________, 20_______. #-100-ORDER APPROVING TRUST PAGE 2 OF 3 Revised 4/07 American LegalNet, Inc. www.FormsWorkflow.com 4. The situs of the trust shall be deemed to be Spokane County, Washington. Unless approved by the Court, all proceedings concerning the administration of the trust shall be brought in the Spokane County Superior Court. 5. The appointment of a successor trustee shall be subject to Court approval. 6. The trust may be amended only by order of this Court. 7. The trustee must file an inventory of trust assets by ___________________, 20_______. In the event additional funding of the trust, the trustee shall file an amended inventory within 30 days thereafter. 8. The trustee shall file an outline of the beneficiaries projected needs and significant disbursements within 30 days of appointment and annually thereafter. DATED AND SIGNED IN OPEN COURT THIS _____ DAY OF ________________, 20____. ____________________________________________ Judge/Court Commissioner Signature of Trustee/Attorney Printed Name of Trustee/Attorney, WSBA/CPG# Address City, State, Zip Code Telephone/Fax Number Email Address Signature of Guardian ad Litem Printed Name of Guardian ad Litem Address City, State, Zip Code Telephone/Fax Number Email Address #-100-ORDER APPROVING TRUST PAGE 3 OF 3 Revised 4/07 American LegalNet, Inc. www.FormsWorkflow.com