Annual Accounting (Personal Needs) {11JD AA-IPPN}

WAA-93 SUPREME COURT COUNTY OF QUEENS --------------------------X IN THE MATTER OF THE ANNUAL INVENTORY AND ACCOUNT OF ANNUAL INVENTORY AND ACCOUNT Index No. / AS GUARDIAN/CONSERVATOR/ COMMITTEE OF ANNUAL ACCOUNT FOR 20 AN INCAPACITATED PERSON/ CONSERVATEE/INCOMPETENT --------------------------x I, --------------- ---------- --------------------, residing at as Guardian/Conservator/Committee for the above named person, do hereby make, render and file the following annual account and inventory. On the day of 2 0 I was duly appointed Guardian/Conservator/Committee of the above named person, by Order of the Supreme Court of Queens County and have continued to act as such fiduciary since that date, giving a bond in the original sum of now in the sum of pursuant to subsequent orders, which is still in force and effect with ---------------------------- , as Surety. There has been no change in the Surety thereon, and the Surety is in good financial standing as when the bond was given. (Note: If there has been a change in the bond; of the Surety thereon, or in the financial standing of the Surety, explain in Schedule %22F%22). The following is a true and full account of all receipts and disbursements for the year 20 SUMMARY Schedule %22A%22 - Principal on hand at date of appointment or last accounting ................ ------------- Schedule %22B%22 - Changes to principal ............. Schedule %22C%22 - Income Received .................. Sub Tota1 ..................................... Schedule %22D%22 - Paid Disbursements .............. Schedule %22E-1%22 - Balance of cash and securities to be charged to next year's account ............ Schedule %22E-2%22 - Real Estate ................... Schedule %22E-3%22 -All other personal property ..... $Total Estate ............................ Attach additional pages if needed. American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE %22A%22 PRINCIPAL ON HAND Either (a) as of date of appointment [if this is a first account] or (b) as of last annual accounting. Identify each item in detail, including name and address of each bank or other financial institution, number of shares of each security, etc. SOURCE AMOUNT TOTAL OF SCHEDULE %22A $ SCHEDULE %22B%22 INCREASE OR DECREASE TO PRINCIPAL Additional property received, gain or loss on sale or liquidation of stocks or bonds, net receipts from sale of realty (attach copy of closing statement), etc. TOTAL OF SCHEDULE %22B%22 American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE %22C%22 RECEIVED INCOME AND CASH INCREASES NOTE: If there have been receipts of principal during the year, so indicate in Schedule B. If property listed in the last accounting has been converted to cash, list the amount received from the sale and attach an explanation. SOURCE AMOUNT TOTAL OF SCHEDULE %22C%22 SCHEDULE %22D%22 PAID DISBURSEMENTS PAID TO AMOUNT TOTAL OF SCHEDULE %22D%22 American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE %22E-1%22 BALANCE ON HAND AND OTHER PERSONAL AND REAL PROPERTY NOTE: List here all bank account; securities; brokerage accounts; personal property. If property is owned jointly with others, give names of joint owners and their relationship to the incapacitated person. List bank account values as of end of accounting period. With respect to securities, list both inventory value and market value as of end of accounting period. DESCRIPTION INVENTORY VALUE MARKET VALUE TOTAL OF SCHEDULE %22E-1%22 $ $ SCHEDULE %22E-211 REAL ESTATE NOTE: List here all real estate owned by the incapacitated person, either in whole or in part, stating its location, assessed value, amount of mortgage (if any), the weekly or monthly rental, and the approximate current market value. If property is owned jointly with others, gives names of joint owners and their relationship to the incapacitated person. SCHEDULE %22E-3%22 ALL OTHER PERSONAL PROPERTY SCHEDULE %22F%22 NAME AND ADDRESS OF THE SURETY State amount of bond and bond number. Attach a copy of the latest bond. American LegalNet, Inc. www.FormsWorkFlow.com AS TO THE INCAPACITATED PERSON: List here the following information: State the age, date of birth and marital status of the Incapacitated Person. 2. List here the name and present address of the spouse, children and siblings of the Incapacitated Person. 3. State the present residence address and telephone number of the Guardian. 4. State the present residence address and telephone number of the Incapacitated Person. If said Incapacitated Person does not presently reside at his or her personal home, set forth the name, address and telephone of the facility or place at which said Incapacitated Person resides, and the name of the chief executive officer of the facility or the person otherwise responsible for the care of the Incapacitated Person. 5. State whether there have been any changes in the physical or mental condition of the Incapacitated Person, and any substantial change in medication. 6. State the date and place the Incapacitated Person was last seen by a physician and the purpose of that visit. 7. Attach a statement by a physician, psychologist, nurse clinician or social worker, or other person who has evaluated or examined the Incapacitated Person within the three months prior to the filing of this report, regarding an evaluation of the Incapacitated Person's condition and the current functional level of the Incapacitated Person. American LegalNet, Inc. www.FormsWorkFlow.com 8. If the Guardian has been charged with providing for the personal needs of the Incapacitated Person, a: attach a statement whether the current residential settings is suitable to the current needs of the Incapacitated Person. b: attach a resume of any professional medical treatment given to the Incapacitated Person during the preceding year. c: state the plan for medical, dental and mental health treatment and related services for the coming year, including the social and personal services currently utilized by the Incapacitated Person, the social skills of the Incapacitated Person, and the social needs of the Incapacitated Person. 9. State whether the Guardian has used or employed the services of the Incapacitated Person, or whether moneys have been earned by or received on behalf of such Incapacitated Person, and provide the details thereof in Schedule %22C%22. 10. Attach a resume of any other pertinent facts relative to the care and maintenance of the Incapacitated Person, including the frequency of your visits; whether the Incapacitated Person has made a Will or executed a Power of Attorney; and any other information necessary for the proper administration of this matter. American LegalNet, Inc. www.FormsWorkFlow.com STATE OF NEW YORK COUNTY OF SS: I, , being duly sworn, say: I am the Guardian/Conservator/Committee for the above-named person. The foregoing account and inventory contains, to the best of my knowledge and belief a full and true statement of all my receipts and disbursements on account of said person; and of all money and other personal property of said person which have come to my hands or have been received by any other persons by my order or authority since my appointment or since filing my last annual account and inventory, and of the value of all such property, together with a full and true statement and account of the manner in which I have disposed of the same and of all property remaining in my hands at the time of filing this account and inventory; also a full and true description of the amount and nature of each investment made by me since my appointment or since the filing of my last account and inventory. I do not know of any error or omission in the account and inventory to the prejudice of said person. Sworn to before me this day of 20 Notary Public GENERAL INSTRUCTIONS Complete all sections of this Annual Inventory and Account, including all schedules. The affidavit should be sworn to before a Notary Public or Commissioner of Deeds. The Annual Inventory and Account shall be filed annually in May of each year for the preceding year, unless otherwise provided by statute, with the court of appointment or the county clerk of the county of appointment, and with the director of the state facility, if any, and a copy sent to the Court Examiner. Statu