(Copy Receipt) (Clerk’s Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF _______________________ In the Trust of: CASE NO. ______________________ _______________________________________ TRUSTEE’S ACCOUNTING AND PROPOSED BUDGET If you need more room to answer any item, please attach an additional page. 1. Date of Appointment and Reporting Period: The Trustee was appointed on ___________. This report covers the period from ____________ through ____________. The closing date for all reports is _______________, and the Trustee is required to file reports within 90 days of that date. The Trustee is to file a report annually. 2. Contact Information: Beneficiary Guardian (if applicable) Trustee Full Name Mailing Address City, State & Zip Telephone Number Fax Number Email Address TRUSTEE’S ACCOUNTING AND PROPOSED BUDGET PAGE 1 OF 8 10/04 American LegalNet, Inc. www.USCourtForms.com 3. Contact Information for Trust Advisory Committee (if applicable): Committee Member Committee Member Committee Member Full Name Mailing Address City, State & Zip Telephone Number Fax Number Email Address 4. Are Trust Advisory Committee members related to the beneficiary? Yes No Specify: ___________________________________________________________________ 5. Relationship, if any, of trustee to beneficiary: ________________________________ 6. Is trustee a residual beneficiary of trust? 7. Is there a bond? Yes No Yes No Amount $___________________ 8. Which trust fund accounts, if any, are blocked? _________________________________ $ a. Trustee’s Bond: The Court now requires a bond in the amount of: $ $ $ b. Total balance in blocked accounts at end of review period: c. Total balance unblocked at end of review period: d. The bond should: remain the same; OR be changed to 9. Have trust reports been prepared annually? Yes No 10. Benefits Received. The Beneficiary receives the following: SSDI/SSA; Stamps; GAU; SSI; Medicaid; Public Assistance; Medicare; VA; Copes; CSA; TANF; HUD; Food Other--Specify: __________________________________________________________ 11. Inventory: An inventory of all trust property is, or is not on file herein. An updated inventory is contained in this Report. TRUSTEE’S ACCOUNTING AND PROPOSED BUDGET PAGE 2 OF 8 10/04 American LegalNet, Inc. www.USCourtForms.com 12. Proposed Budget: The Trustee seeks authority to make expenditures for the Incapacitated Person or beneficiary according to the proposed attached budget. 13. Fees: If Trustee and/or attorney fees are requested, attach or submit a separate, itemized fee declaration which describes the specific services rendered, the time required, the rate of compensation, and the out-of-pocket costs incurred. Trustee $_____________ Attorney $_______________ Accountant $______________ 14. Court Approval: The trustee petitions the Court for approval of this Accounting and Proposed Budget. TRUSTEE’S ACCOUNTING AND PROPOSED BUDGET PAGE 3 OF 8 10/04 American LegalNet, Inc. www.USCourtForms.com ACCOUNTING SUMMARY FORM FOR TRUSTEES 15. Estate Information For Accounting Period starting ____________ and ending _____________. A. Total Assets at Market Value as of the beginning of review period $______________. SET FORTH TOTAL FIGURES FOR ENTIRE ACCOUNTING PERIOD. DO NOT USE MONTHLY FIGURES. Income Received from All Sources (do not include new assets purchased) Wages & Benefits Wages Social Security Retirement Benefit Disability Health Insurance Benefits Other (Specify): CURRENT MONTHLY BENEFIT TOTAL RECEIVED $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Interest & Dividends List account and amount received: Other Receipts List source and amount received: B. Total Income: Disbursements and Outgoing Payments Personal Living Expenses Housing/Facility/Rent Companion/Attendant Care Food and Groceries Incidentals/Clothing Utilities Phone/Cable Insurance TRUSTEE’S ACCOUNTING AND PROPOSED BUDGET $__________________ TOTAL $ $ $ $ $ $ $ $ PAGE 4 OF 8 10/04 American LegalNet, Inc. www.USCourtForms.com Personal Allowance Auto and Transportation Other (Specify): $ $ $ Healthcare Expenses Medical/Dental Pharmaceutical Medical Transportation Health Insurance Outside Case Management Fees Other (Specify): $ $ $ $ $ $ Trustee Fees Trustee Fees $ Professional Fees Paid to Others Guardian ad Litem Fees Attorney Fees: for Trustee Attorney Fees: for Asset Management Fees Bond Premium Medical Claims Assistance Accountant/Tax Preparation Fees Other (Specify): $ $ $ $ $ $ $ $ Real Property Expenses: Residence Maintenance & Repair Homeowners/Co-op Dues Property Taxes Mortgage Insurance Other (Specify): $ $ $ $ $ $ Investment Property Expenses $ Other Expenses Employment Tax Income Tax Payments Costs Advanced Bank/Service Fees Other (Specify): C. Total Disbursements TRUSTEE’S ACCOUNTING AND PROPOSED BUDGET $ $ $ $ $ $__________________ PAGE 5 OF 8 10/04 American LegalNet, Inc. www.USCourtForms.com Adjustments to Market Value of Estate Addition of Assets/(Liabilities) Not Previously Reported (Do not use this section for assets purchased) $ $ Deletion or Reduction in Value (Assets)/Liabilities Listed on previous accounting $ $ Gifts Received/(Made) Date of Court Order Authorizing $ $ Net Gains/(Losses) from Sales of Assets $ $ Unrealized Gains/(Losses) Increase/(decrease) in unrealized gain on securities Increase/(decrease) in market value of real property Increase/(decrease) in market value of personal property Other Adjustments (Specify) $ $ $ $ D. Total Adjustments to Market Value of Estate: $_________________ E. Ending Balance at Market Value, as of _______________ $____________________ (A + B –C +/- D = E) 16. Balance Sheet for the Trust Estate ASSETS Description Market Value on Start of Accounting Date: Market Value at End of Accounting Date: $ $ Accounting: Cost Basis at End of Accounting Date: $ $ $ $ Real Property TRUSTEE’S ACCOUNTING AND PROPOSED BUDGET PAGE 6 OF 8 10/04 American LegalNet, Inc. www.USCourtForms.com Receivables (Mortgages, Liens, Notes payable to the Incapacitated Person, the Estate, or Trust) $ $ $ $ $ $ Blocked Liquid Assets (Investment Accounts, Stocks, Bonds, Securities, IRA, Cash in Court Blocked Accounts) $ $ $ $ $ $ $ $ $ Unblocked Liquid Assets (Investment Accounts, Stocks, Bonds, Securities, IRA, Cash) $ $ $ $ $ $ $ $ $ Personal and Other Property (Household Goods, Vehicles, Burial Plots, Funeral Plans, Life Insurance) $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL ASSETS: $ $ $ $ $ $ $ $ at Cost Basis $ at Market Value $ at Market Value LIABILITIES TOTAL LIABILITIES: 17. . NET TOTAL ESTATE: Supporting Documents: Cancelled checks, (if not available, copies of cancelled checks or copies of check registers), monthly bank statements, brokerage statements, and an itemized list of all transactions must be included for each account for the reporting period to support the declarations made in this report. The supporting documents must be submitted to the Court Administrator’s Office with a copy of this report. Do not file the supporting documentation in the court legal file. TRUSTEE’S ACCOUNTING AND PROPOSED BUDGET PAGE 7 OF 8 10/04 American LegalNet, Inc. www.USCourtForms.com 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 in this Trustee’s Report, Accounting, and Proposed Budget and attached Accounting Summary are true and correct and hereby petition the Court for approval. SIGNED AT ___________, WASHINGTON THIS _____ DAY OF _____________, 20___. Signature of Trustee(s) Printed Name of Trustee(s) Address Telephone/Fax Number City, State, Zip Code Email Address TRUSTEE’S ACCOUNTING AND PROPOSED BUDGET PAGE 8 OF 8 10/04 American LegalNet, Inc. www.USCourtForms.com