Statement Identifying Real Property

STATEMENT IDENTIFYING REAL PROPERTYPursuant to Mental Hygiene Law 24781/20 (a)(6) (vi) Record and Index: Incapacitated Person Address Guardian of Property Address [] Check box if there is/are Co-Guardians of the property and List Below Guardian of Property Address Guardian of Property Address Adjudication of Incapacity: Supreme Court Nassau County Index NumberDate of Order and Judgment Date of Decision/Verdict Surety Name: Bond Number: Phone Number: American LegalNet, Inc. www.FormsWorkFlow.com Real Property Address Tax Map Desgination:Name of Municipality: Section Block Lot Signature of GuardianCo-Guardian Name of GuardianName of Co-Guardian State of New York County of } ss: On this day of , before me came Name of GuardianName of Co-Guardianto me know to be the individuals described herein, and who executed the foregoing instrument andacknowledged that he/she/they executed same. Notary Public American LegalNet, Inc. www.FormsWorkFlow.com