Fiduciarys Periodic Or Final Account {PC-441}

Fiduciary222s Periodic or Final Account/ Conservator/Guardian PC - 441 REV. 7/19 CONNECTICUT PROBATE COURTS Fiduciary222s Periodic or Final Account/Conservator/Guardian PC - 441 Page 1 of 3 RECEIVED: Instructions: 1) A fiduciary may use this form to account for a conservatorship or guardianship unless the court has ordered the fiduciary to submit an account or Probate Court Rules of Procedure, section 38.1, requires a separate principal and income accounting. 2)Report all assets at fiduciary acquisition value unless otherwise indicated. See Probate Court Rules ofProcedure, section 36.14. 3)Attach supporting schedules as required under Probate Court Rules of Procedure, section 38.2(d).4)The fiduciary must send a copy of this account to each party and attorney and certify to the court that acopy has been sent.5)For further information, see C.G.S. section 45a-175 et seq. and Probate Court Rules of Procedure, rules36 through 38.6)Type or print in ink. Use an additional sheet, or PC-180, if more space is needed. Probate Court Name District Number Estate of Hereinafter referred to as the estate Fiduciary (Name , address and telephone number of each fiduciary ) Position of Trust Type of estate: Conservator Guardian of estate of minor Guardian of adult with intellectual disabilities Other Periodic account Final Account This account covers the time period (Month, Day, Year) from to The fiduciary represents that: 1) The following is a true and complete account of all assets of the estate and the fiduciary222s receipts, payments and distributions . 2) If this is a final account, all claims against the estate and administration expenses have been paid, except as noted below. 3)All supporting records for this account have been retained as required by Probate Court Rules of Procedure,section 36.13, and the records are available for review upon request. ASSETS AND INCOME RECEIVED BY FIDUCIARY Total amount reported on the inventory or at the end of the last accounting period Total amount of additional assets received [Attach schedule.] Cash advanced to the estate by Does the person who advanced funds expect reimbursement? Yes No Income received [Attach schedule.] American LegalNet, Inc. www.FormsWorkFlow.com Fiduciary222s Periodic or Final Account/ Conservator/Guardian PC - 441 REV. 7 /19 CONNECTICUT PROBATE COURTS Estate of Fiduciary222s Periodic or Final Account/Conservator/Guardian PC - 441 Page 2 of 3 Gains realized on the sale of assets [Attach schedule; if real property has been sold, attach settlement statement from closing in addition to schedule.] Adjustments increasing fiduciary acquisition value [Attach schedule.] Total assets and income received by fiduciary: PAYMENTS AND DISTRIBUTIONS BY FIDUCIARY AND ESTATE ON HAND Administration expenses [Attach schedule.] Losses realized on the sale of assets [Attach schedule; if real property has been sold, attach settlement statement from closing in addition to schedule.] Adjustments decreasing fiduciary acquisition value [Attach schedule.] Payments or distributions made to or for the benefit of [ Insert name and attach schedule. ] Assets on hand at the end of the accounting period [Attach schedule of assets on hand at fiduciary acquisition value and fair market value.] If final account, attach schedule of proposed distribution and reserve Total payments and distributions by fiduciary: CASH RECONCILIATION Cash reported on inventory or last account Income Additional cash receipts Proceeds from sale of assets Other cash transactions Total cash received by fiduciary: Administration expenses Purchase of assets Payments or d istributions Other cash transactions Cash on hand Total cash payments and distributions by fiduciary: WHEREFORE each fiduciary requests that the court approve this account, approve and order distribution in accordance with the schedule of proposed distribution attached hereto, and release each fiduciary from liability with respect to all items shown in this account. The representations made in this account are made under penalty of false statement. Signature of Fiduciary Type or Print Name Date Signature of Fiduciary Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com Fiduciary222s Periodic or Final Account/ Conservator/Guardian PC - 441 REV. 7 /19 CONNECTICUT PROBATE COURTS Estate of Fiduciary222s Periodic or Final Account/Conservator/Guardian PC - 441 Page 3 of 3 CERTIFICATION I certify that a copy of this account was sent to the following persons as provided in the Probate Court Rules of Procedure, section 30.12: Name and Address Signature of Fiduciary or Attorney Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com