Inventory Of Safe Deposit Box Contents {CM58}

In the matter of: , a person with a disability /a minor IN THE COURT OF CHANCERY OF THE STATE OF DELAWARE Register in Chancery Kent County 38 The Green , Ste. 208 Dover, DE 19901 302 - 73 5 - 1930 Register in Chancery New Castle County 500 N. King Street , Ste. 11600 Wilmington, DE 19801 302 - 255 - 0544 Register in Chancery Sussex County 34 The Circle Georgetown, DE 19947 302 - 856 - 5775 In the Matter of: : : , : C.M. # a person with a disability /a minor : Accounting Number: [First, Second, Third, ] or Final Please circle or fill - in the appropriate number Accounting Period: to Beginning Date Ending Date Date Guardian (s) was /were appointed: address: If applicab le: Co - Co - Co - PLEASE NOTE: THE GUARDIAN (S) MUST ATTACH TO EACH ACCOUNTING, EXCEPT THE FIRST SIX MONTH ACCOUNTING AND THE FINAL ACCOUNTING, THE ANNUAL UPDATE AND MEDICAL STATEMENT. Rev. 0 5 / 20 1 8 American LegalNet, Inc. www.FormsWorkFlow.com In the matter of: , a person with a disability /a minor Additional Information Regarding Accountings (Please see the Court of Chancery Rules for further information) The Guardian(s) is/are required to file an accounting of this estate at least once every year. The guardian (s) shall file the first accounting for a period of six months beginning with the date of his/her/ their appointment as guardian (s) , which accounting is due nine (9) months from his/her/ their appointment. Each subsequent accounting shall cover a twelve (12) month period and shall begin on the date following the date the previous accounting end ed . The annual accountings are due on or before the first business day of the calendar quarter in which the guardian was appointed, and at such other times as the Court may direct. If additional space is required on schedules, please insert sheets of the same size. All items must be listed as separate entries ( e.g. Social Security must be listed each month it was received, not as one lump payment). Spreadsheets can be filed as an attachment to any schedule. The g uardian(s) signature (s) must be notarized on either the C - 16 - A or C - 16 - B form (the last two pages of th is packet ). The g uardian(s) is/are required to provide cancelled checks, bank statements, receipts and any other pertinent information to show how the money of the person with a disability was used (per Chancery Rule 120). Once your accounting has been a udited by the Register in Chancery c lerk, a bill will be mailed to the guardian(s); the fees are based on Chancery Rule 3(bb). In addition, the guardian(s) will be charged a $10.00 fee for the clerk to electronically file the accounting. Supporting docum ents ( e.g . bank statements and receipts ) are not kept by the Register in Chancery after the accounting has been reviewed by the Judicial Officer , so please select one of the following options: As the guardian(s), I wish for all supporting documentation t o be - Shredded by the Register in Chancery c lerk Returned to the guardian (If you choose this box, you will be called and given thirty days to pick up the documents or they will be shredded. You may also choose to give the clerk a pre - paid envelope for the items to be returned to you.) I have read the accounting instructions. Guardian Date Co - Guardian Date American LegalNet, Inc. www.FormsWorkFlow.com In the matter of: , a person with a disability /a minor SUMMARY SCHEDULE TITLE VALUE A PRINCIPAL ON HAND $ B ADDITIONS TO PRINCIPAL $ C INCOME RECEIVED $ TOTAL: $ D DEDUCTIONS FROM PRINCIPAL $ E INCOME PAID OUT $ TOTAL: $ F PRINCIPAL REMAINING ON HAND $ ***PLEASE NOTE THAT A COPY OF ALL BANK STATEMENTS, RECEIPTS AND INVOICES PAID DURING THE ACCOUNTING PERIOD MUST BE FILED WITH THE ACCOUNTING. American LegalNet, Inc. www.FormsWorkFlow.com In the matter of: , a person with a disability /a minor SCHEDULE A AMOUNT OF PRINCIPAL ON HAND ON (Date). This amount should be the same amount of the original principal reported in the inventory if this is a First Accounting or the ending principal of the last account ing . (This schedule includes all bank accounts, real esta te owned by the person with a disability , household furnishings, automobiles, all miscellaneous furnishings, etc.,) DESCRIPTION OF ASSET VALUE $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ American LegalNet, Inc. www.FormsWorkFlow.com In the matter of: , a person with a disability /a minor SCHEDULE B ADDITIONS TO PRINCIPAL, WHEN MADE, AND THE SOURCE FROM WHICH THEY WERE OBTAINED. This should include Capital Gain in stock, sale of real estate , etc. Please state : (1) the date of the transaction, (2) the description of the investment and (3) the gain realized. DATE OF TRANSACTION DESCRIPTION OF INVESTMENT GAIN REALIZED $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ American LegalNet, Inc. www.FormsWorkFlow.com In the matter of: , a person with a disability /a minor SCHEDULE C INCOME RECEIVED, WHEN RECEIVED AND FROM WHAT SOURCE. This schedule should include any and all income received such as social security, pension, alimony, certificate of deposit interest , dividends and interest from stock, interest on savings accounts, income from rental properties , etc . DATE TRANSACTION DESCRIPTION VALUE $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ American LegalNet, Inc. www.FormsWorkFlow.com In the matter of: , a person with a disability /a minor SCHEDULE C , cont. INCOME RECEIVED, WHEN RECEIVED AND FROM WHAT SOURCE. This schedule should include any and all income received such as social security, pension, alimony, certificate of deposit interest , dividends and interest from stock, interest on savings accounts, income from rental properties , etc . DATE TRANSACTION DESCRIPTION VALUE $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ American LegalNet, Inc. www.FormsWorkFlow.com In the matter of: , a person with a disability /a minor SCHEDULE D DEDUCTIONS FROM PRINCIPAL, WHEN MADE AND FOR WHAT PURPOSE. This schedule should include actual losses on investments. Examples are capital losses on stocks, and/or losses from sale of property. (If a household article was appraised at $2000.00, but sold for $1,500.00 , this would result in a $500.00 loss). DATE TRANSACTION DESCRIPTION VALUE $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ American LegalNet, Inc. www.FormsWorkFlow.com In the matter of: , a person with a disability /a minor SCHEDULE E INCOME PAID OUT \ EXPENSES PAID , TO WHOM, WHEN PAID, AND FOR WHAT PURPOSE. This schedule should include all income paid out for the benefit of the person with a disability (also include any and all bank service charges). DATE CHECK # TO WHOM/CREDITOR AND PURPOSE AMOUNT $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ American LegalNet, Inc. www.FormsWorkFlow.com In the matter of: , a person with a disability /a minor SCHEDULE E , cont. INCOME PAID OUT \ EXPENSES PAID , TO WHOM, WHEN PAID, AND FOR WHAT PURPOSE. This schedule should include all income paid out for the benefit of the person with a disability (also include any and all bank service charges). DATE CHECK # TO WHOM/CREDITOR AND PURPOSE AMOUNT $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ American LegalNet, Inc. www.FormsWorkFlow.com In the matter of: , a person with a disability /a minor SCHEDULE E , cont. INCOME PAID OUT \ EXPENSES PAID , TO WHOM, WHEN PAID, AND FOR WHAT PURPOSE. This schedule should include all income paid out for the benefit of the person with a disability (also include any and all bank service charges). DATE CHECK # TO WHOM/CREDITOR AND PURPOSE AMOUNT $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ American LegalNet, Inc. www.FormsWorkFlow.com In the matter of: , a person with a disability /a minor SCHEDULE F PRINCIPAL ON HAND AT THE END OF THE ACCOUNTING PERIOD. This schedule should include the remaining balance in all bank accounts after all deductions and additions are made. Th is schedule should also include any real or personal property of the person with a disability that is still in their possession (which has not been sold). Please include the source and the amount. SOURCE VALUE $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ American LegalNet, Inc. www.FormsWorkFlow.com In the matter of: , a person with a disability /a minor LIST OF BENEFICIARIES/INTERESTED PARTIES The following is