Statement Of Need And Projected Disbursements {104}

(Copy Receipt) (Clerk's Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In the Trust of: CASE NO. _______________________ STATEMENT OF NEED AND PROJECTED DISBURSEMENTS (ST) _________________________________ Beneficicary The trustee submits the following information regarding the trust beneficiary: 1. Outline of Disabilities or Special Needs of the Beneficiary, if any. _______________ ______________________________________________________________________ 2. Age and Living Circumstances of the Beneficiary, i.e. home with parent, adult family home. _______________________________________________________________ 3. Projected Recurring Monthly Disbursements. Room and Board Medical Rent/Mortgage Personal and Incidental Expenses Food and Household Expenses Utilities Trustee Fees Other Total Proposed Monthly Expenditures $ $ $ $ $ $ $ $ $ STATEMENT OF NEED AND PROJECTED DISBURSEMENTS (ST) - PAGE 1 OF 2 SPO TRU 02.0104 (02/2008) American LegalNet, Inc. www.FormsWorkFlow.com 4. Significant Extraordinary Disbursements Anticipated During the Next Year, i.e. purchase of real estate, wheelchair accessible van. _______________________________________________________________________ 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 Trustee(s) Printed Name of Trustee(s), WSBA/CPG# Address City, State, Zip Code Telephone/Fax Number Email Address STATEMENT OF NEED AND PROJECTED DISBURSEMENTS (ST) - PAGE 2 OF 2 SPO TRU 02.0104 (02/2008) American LegalNet, Inc. www.FormsWorkFlow.com