Fill and Sign the This is an Accurate Account of the Administration of the Trust for the Period from Date Form

PR-1937, 10/10 Trustee's Account (Informal Administration and Forma l Administration) §701.16(4) and (5), W isconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 1 of 3 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY For Official Use IN THE MATTER OF THE ESTATE OF For the following trust: Amended Trustee's Account Annual Interim Final Informal Administration Formal Administration Case No. This is an accurate account of the administration of the trust for the period from (Date) through (Date) . Summary Line Description (Attach Schedules) Balance 1. Beginning Balance. Do no t change any pre-printed amount. (Inventory total value or ending balance from prior account.) $ 2. Total assets and income received from Schedule A (Page 1). (Add) $ 3. Subtotal $ 4. Total expenses, distributions and losses incurred from Schedule B (Page 2.) (Subtract) $ 5. Total assets on hand from Schedule C (Page 3.) TOTAL $ STOP! YOU MUST SIGN THIS FORM IN FRONT OF A NOTARY. State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: ► Trustee Name Printed or Typed Address Telephone Number Date State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: ► Trustee Name Printed or Typed Address Telephone Number Date Form completed by: (Name) Address Telephone Number Bar Number (If any) Trustee's Account (Informal Administration and Formal Administration) Page 2 of 3 Case No. PR-1937, 10/10 Trustee's Account (Informal Administration and Formal A dministration) §701.16(4) and (5), W isconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 2 of 3 (If the space given is insufficient for any item, attach additional sheets.) See attached Schedule A – Assets and Income Received Description (Example: Interest, dividends, rental and other income, gains from a ssets sold for more than inventory value, or purchase price if acquired after the initial inventory.) Amount $ TOTAL: $ (Enter in Summary on Line 2 on page 1) See attached Schedule B – Expenses, Distributions and Losses Incurred Description (Example: Distributions to or for beneficiary, expenses of the trust, as sets sold for less than inventory value, or purchase price if acquired after the initial inventory.) Amount $ TOTAL: $ (Enter in Summary on Line 4 on page 1) Trustee's Account (Informal Administration and Formal Administration) Page 3 of 3 Case No. PR-1937, 10/10 Trustee's Account (Informal Administration and Formal A dministration) §701.16(4) and (5), W isconsin Statutes This form shall not be modified. It may be supplemented with additional mater ial. Page 3 of 3 See attached Schedule C – Assets on Hand (at end of accounting period) Description (Example: Cash, Checking Accounts, Savings Accounts, Cert ificates of Deposit, including Names and Account Numbers ; Investments; Real Estate, Including Encumbrances) Amount (List balance at end of accounting period; inventor y value, or purchase price if acquired after the initial inventory.) $ TOTAL: $ (Enter in Summary on Line 5 on page 1) For Authorized Persons Only: Display and Verification of Assets I am not the trustee and I am authorized by the court to verify assets . I have examined all securities, evidences of deposit and investments; and such assets correspond with the account, except as indicated. Date of verification: ► Signature (Not Trustee) Name Printed or Typed and Title Telephone Number Date