(Copy Receipt) (Clerk’s Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In the Guardianship of: CASE NO. _______________________ __________________________________ PETITION AND DECLARATION FOR WITHDRAWAL FROM BLOCKED FINANCIAL ACCOUNT 1. Identity of Petitioner, Funds To Be Withdrawn and Reason For Withdrawal. I am the Court-appointed Guardian or Guardian ad Litem in this action. I am the custodian of the funds of the above-named Incapacitated Person. At this time I am seeking a Court order authorizing a withdrawal from account # _______________ (last four digits only), type of account __________________________, held at the following named financial institution: ____________________________________ in the amount of $_____________________ for the following reason or purpose(s): _______________________________________________ OR The Incapacitated Person named above became 18 years old on ___________________. I am the person named above OR I am the Court-appointed Guardian or Guardian ad Litem. I am seeking to have the blocked account funds distributed and to have the Guardianship terminated. I am attaching a copy of a current account statement. #57A-PETITION & DECL FOR WITHDRAWL FROM BLOCKED FINAN ACCT PAGE 1 OF 2 Revised 4/07 American LegalNet, Inc. www.FormsWorkflow.com 2. Documents Required To Be Submitted with Petition for Withdrawal for Any Reason Other than the Incapacitated Person Reaching Age 18. I understand that according to law [RCW 11.92.040(3)], I am required to provide an inventory and accounting prior to the Court’s considering this withdrawal. Attached to this application is: (a) An inventory of assets which came into my hands at the time I was appointed in this proceeding; (b) An accounting of all income, receipts, and expenditures received or made from the date of the Inventory or the date of the last Accounting. (c) If the person requesting the withdrawal is the parent of the Incapacitated Person who is a minor and the reason for the withdrawal is other than because the minor reached 18 years of age, I have completed the attached Financial Statement of my spouse and myself, which demonstrates why we are not able to pay for the item or services for which we are seeking this withdrawal. 3. Statement Regarding Repayment The funds withdrawn shall not be subject to repayment, OR shall be repaid according to the following terms: _______________________________ I certify (or declare) under penalty of perjury under the laws of the State of Washington that to the best of my knowledge the statements above are true and correct. SIGNED AT _____________, WASHINGTON THIS ____ DAY OF ____________, 20____ Signature of Guardian/Attorney Printed Name of Guardian/Attorney, WSBA/CPG# Address City, State, Zip Code *Telephone/Fax Number Email Address *Under GR 22 (b) (6), parties’ personal telephone number(s) are confidential information. If you do not want your personal phone number(s) on this public form, complete form #S2-Sealed Confidential Information and file in the confidential file. #57A-PETITION & DECL FOR WITHDRAWL FROM BLOCKED FINAN ACCT PAGE 2 OF 2 Revised 4/07 American LegalNet, Inc. www.FormsWorkflow.com