Statement Of Additional Information {20.0D}

PROBATE COURT OF FRANKLIN COUNTY, OHIO LAWRENCE A. BELSKIS, JUDGE ROBERT G. MONTGOMERY, JUDGE IN THE MATTER OFTHE CONSERVATORSHIP OF CASE NO. PC-C-20.0D (REV. 3/2001) STATEMENT OF ADDITIONAL INFORMATION Now comes the prospective conservator of the above captioned person, and being first duly sworn, answers the following questions with respect to this conservatorship. 1. Why is this conservatorship necessary 2. Specifically, is the conservatee eligible for or receiving any of the following benefits, and, if so, where are they or their source located? TYPE NAME $ AMOUNT PER MONTH Social Security ............................................................................................ P.E.R.S ....................................................................................................... Veterans Admin ........................................................................................... R.R. Retirement Employees Pension Insurance Benefits Other Other case number, name and location of Court, or trustee, etc. ................. ................. ................. ................. ................. 3. Does the prospective conservatee have an interest in an estate or trust? If so, give the decedents name, Court 4. Does the prospective conservatee have an expectancy from any settlement? If so, give the defendants name or his insurers name, and the amount expected. Case No. Amount Involved: (OVER) FRANKLIN COUNTY FORM 20.0D - STATEMENT OF ADDITIONAL INFORMATION American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. 5. Bank Accounts? INSTITUTION ADDRESS ACCOUNT $ AMOUNT 6. Securities? ISSUER $ MARKET VALUE 7. Land Installment Contracts? VENDEE & ADDRESS PROPERTY LOCATION $ AMOUNT PER MONTH AND BALANCE 8. Rental From Real Estate? ADDRESS OF REAL ESTATE $ AMOUNT PER MONTH 9. Interest In Real Estate? ADDRESS OF REAL ESTATE 10. Income From Any Other Source? Conservator American LegalNet, Inc. www.FormsWorkFlow.com