Free q District Court q Denver Probate Court - Colorado

District Court Denver Probate Court __________________________________ County, Colorado Court Address: _________________________________________ In the Interests of: _________________________________________ Protected Person Attorney or Party Without Attorney (Name and Address): _______________________________________ _______________________________________ Phone Number: ________________ E-mail:____________________ FAX Number:__________________ Atty. Reg. #:________________ COURT USE ONLY Case Number:__________________

Division_____ Courtroom ________

CONSERVATOR'S REPORT ANNUAL REPORT AMENDED REPORT CURRENT REPORTING PERIOD FROM ________________TO __________________ (MM/DD/YYYY) (MM/DD/YYYY) INTERIM REPORT DUE ON _________________________ FINAL REPORT
If Final Report, indicate why: Protected Person deceased Minor turned 21 Judicial Order The Conservator's Report pursuant to §15-14-420, C.R.S. must be filed annually and served on all interested persons and the protected person pursuant to §15-14-404(4), C.R.S., unless otherwise ordered. Summarize the financial activity below after completing the detailed accounting information in Parts II and III. Attach additional sheets if necessary. Notice to Interested Person. Interested persons have the responsibility to protect their own rights and interests within the time and in the manner provided by the Probate Code, including the appropriateness of disbursements, the compensation of fiduciaries, attorneys, and others, and the distribution of estate assets. Interested persons may file an objection with the Court. The Court will not review or adjudicate these or other matters unless specifically requested to do so by an interested person.

Summary of Net Worth - Fair Market Value of Assets Minus Liabilities/Debts
Last Day of Prior Reporting Period (or Inventory) (A) Total Assets from Part II Item 1 $ _____________ Last Day of Current Reporting Period $ _____________ $ _____________ $ _____________

(B) Total Liabilities/Debts from Part II Item 2 $ _____________ (A) minus (B) = Net Worth from Part II Item 3 $ _____________

Summary of Financial Activity
Prior Reporting Period (or Financial Plan) (A) (B) Total Receipts/Income from Part III Item 1 Total Disbursements/Expenses from Part III Item 2 $ _____________ $ _____________ $ _____________ Current Reporting Period $ _____________ $ _____________ $ _____________

(A) minus (B) = Net Income from Part III Item 3

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Protected Person's Information: _____________________________________ (Name)
Current Address: ____________________________________________________________________________ (Include Name of Living Center or Nursing Home) City: ______________________ State: ______________________ Zip Code: __________________ Telephone Number: ______________________________________ Age: ________

Conservator's Information: ________________________________________ (Name)
Did you receive any fees for being the Conservator during this reporting period? Yes No If Yes, indicate hourly rate: $_________ Occupation: _____________________ Your Relationship to Protected Person: _________________________ Address: __________________________________________________________________ Apt. #__________ City: ______________________ State: ______________________ Zip Code: __________________ Telephone Numbers: Home ___________________ Work ____________________ Cell ___________________ E-Mail Address: _____________________________________________________________________________

If applicable, Co-Conservator's Information: ______________________________ (Name)
Did you receive any fees for being the Conservator during this reporting period? Yes No If Yes, indicate hourly rate: $_________ Occupation: _____________________ Your Relationship to Protected Person: _________________________ Address: __________________________________________________________________ Apt. #__________ City: ______________________ State: ______________________ Zip Code: __________________ Telephone Numbers: Home ___________________ Work ____________________ Cell ___________________ E-Mail Address: _____________________________________________________________________________

Part I ­ Conservatorship Issues
1. Yes No If No, describe why and what steps Is there a continued need for the Conservatorship? should be taken. If you would like the Court to take action, you must file a motion with the Court. ____________________________________________________________________________________ ____________________________________________________________________________________ 2. Are the remaining assets in the estate sufficient to provide for the present and future care of the protected Yes No If No, describe why and what steps should be taken. If you would like the Court person? to take action, you must file a motion with the Court. ____________________________________________________________________________________ ____________________________________________________________________________________ 3. Attach a copy of the Bond to this Report, unless the Bond was waived or not required by the Court. What is the amount of the Bond? $ ________________. Is the amount of the Bond sufficient to cover all unrestricted assets? Yes No If No, describe why and what steps should be taken. If you are requesting a change to the Bond, you must file a motion with the Court. ____________________________________________________________________________________ ____________________________________________________________________________________

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Part II ­ Assets and Liabilities/Debts
Yes No If Yes, use the amounts from the Inventory with Is this the first Conservator's Report filed? Financial Plan (JDF 882) to complete the column marked with an asterisk (*) in Items 1 and 2 below. If No, use the amounts from the prior Conservator's Report filed to complete the column marked with an asterisk (*) in Items 1 and 2 below.

1. Assets
Description of Asset
(Identify all accounts)

Account Number
(last 4digits only)

Name of Financial Institution

* Fair Market
Value
as of Last Day of Prior Reporting Period or Inventory

Fair Market Value
(as of Last Day of Current Reporting Period)

Change in Value of Asset

Checking Accounts Savings Accounts Other Cash Accounts
(e.g. Money Markets and CD's)

Stocks Bonds Mutual Funds Other Financial Investments Life Insurance (Cash
Value)

Pension and Retirement Funds
(Vested portion)

IRA's Annuities Motor Vehicles Real Estate (report
mortgage in liability/debt section)

Home Furnishings Collections (e.g., stamps
or coins)

Other Assets (Please list)

Total Assets Enter these amounts on page 1.
Have Total Assets changed from the last day of the Prior Reporting Period or Inventory? Yes No If Yes, briefly explain the changes below. Please include a description of any significant or unanticipated transactions. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

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2. Liabilities/Debts
Description of Liability/Debt
(Identify all accounts)

Account Number
(last 4digits only)

Name of Financial Institution

*Value on Last
day of Prior reporting Period or Inventory

Last Day of Current Reporting Period

Change in Amount of Liability

Mortgages (principal due
only)

Car Loans Home Improvement Loans Student Loans Credit Card Debt Federal Taxes Owed State and Local Taxes Owed
Other Liabilities/Debts
(Please list)

Total Liabilities/Debts Enter these amounts on page 1.
Have Total Liabilities/Debts changed from the last day of the Prior Reporting Period or Inventory? Yes No If Yes, briefly explain the changes below. Please include a description of any significant or unanticipated transactions. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

3. Net Worth ­ Fair Market Value of Assets Minus Liabilities/Debts
Last Day of Prior Reporting Period or Inventory Last Day of Current Reporting Period

Net Worth Assets minus Liabilities/Debts (Item 1 Total minus Item 2 Total)

Enter these amounts on page 1.

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Part III ­ Receipts/Income and Disbursements/Expenses
Yes No If Yes, use the amounts from the Inventory with Is this the Initial Conservator's Report filed? Financial Plan (JDF 882) to complete the column marked with an asterisk (*) in items 1 and 2, below. If No, use the amounts from the prior Conservator's Report filed to complete the column marked with an asterisk (*) in items 1 and 2, below.

1. Total Receipts/Income
Description of Receipt/Income Category

*Total Amount of
Receipts / Income from Prior Reporting Period or Financial Plan

Total Amount of Receipts / Income for Current Reporting Period

Change in Amount of Receipt/ Income

Wages Social Security Interest / Dividends Pensions / Retirement Plan Distributions Tax Refunds Proceeds from Sales of Assets Rental Income Gifts from Others Disability, Unemployment or Worker's Compensation Other Public Assistance Other Receipts / Income (Please list)

Total Receipts/Income Enter these amounts on page 1. Yes No Have Total Receipts/Income changed from the Prior Reporting Period or Financial Plan? If Yes, briefly explain the changes below. Please include a description of any significant or unanticipated transactions. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

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2. Disbursements/Expenses
Description of Disbursement / Expense Category

*Total Amount of
Disbursement / Expense from Prior Reporting Period or Financial Plan

Total Amount of Disbursement / Expense for Current Reporting Period

Change in amount of Disbursement/ Expense

Total Professional Fees Paid (from Part IV. Item 1 ­ Payment to Professionals) Distributions to Protected Person Income Taxes FICA and Medicare Taxes Health Care (including health insurance and prescriptions) Other Insurance Rent or Mortgage Property Taxes and Assessments Repairs and Maintenance Utilities, including phones Home Furnishings Food and Household Supplies Clothing Personal Care Auto Expenses Education Entertainment, Vacations and Travel Other Disbursements/Expenses, e.g. gifts (Please list)

Total Disbursements/Expenses Enter these amounts on page 1. Have Total Disbursements/Expenses changed from the Prior Reporting Period or Financial Plan? Yes No If Yes, briefly explain the changes below. Please include a description of any significant or unanticipated transactions. __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

3. Net Income ­ Total Receipts/Income Minus Total Disbursements/Expenses
Net Income Receipts/Income minus Disbursements/Expenses (Item 1 Total minus Item 2 Total) Enter these amounts on page 1. Prior Reporting Period or Financial Plan Current Reporting Period

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Part IV ­ Payments to Professionals
1. List below payments to professionals that you are employing to serve you, as conservator, the protected person or the estate; and the amounts paid to such professionals during this reporting period. Include any fees you received as the Conservator. Type of Professional and Name of Individual Total Amount Paid in Current Reporting Period

Conservator Guardian Guardian ad litemLegal fees for Protected Person Legal fees for Conservator Legal fees for Guardian Legal fees for Petitioner Accountant/CPA Case Manager Other: Describe Other: Describe Other: Describe Other: Describe Total Professional Fees Paid Enter total in Part III, Item 2.

2. For each professional listed above, provide the following for the current reporting period: Name, hourly rate charged (may include range of hourly rates, if applicable), number of hours worked, total hourly fees, other costs charged and a brief description of the services provided and benefit to the estate. The sum of the total hourly fees and other costs charged for each professional listed in the chart below, should equal the total amount paid in the current reporting period in Item 1, above for that professional. Name of Professional Hourly Rate (Range) No. of Hours Worked Total Hourly Fees Other Costs Charged Brief Description of Services Provided and Benefit to the Estate

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Part V ­ Detail Listing of Receipts/Income and Disbursements/Expenses
For each bank account included in Part II, Item 1, list below each individual item of Receipts/Income or Disbursements/Expenses for the entire reporting period. If applicable, add additional pages and/or a separate listing if more than one bank account. Each Receipt/Income should be listed in the Amount Received column and each Disbursement/Expense should be listed in the Amount Disbursed column. Note: This report should resemble a check register for each bank account. Name of Bank: __________________________________ Account Number (last 4-digits only): ___________

Beginning Cash Balance

$ _____________ (This should match the ending balance from the last report)

Add: Total Amount Received $ _____________ (Enter total from listing below) Less: Total Amount Disbursed$ _____________ (Enter total from listing below) Ending Cash Balance $ _____________ (This will be the beginning balance on next year's report)

Date

Check or I.D. No.

Description of item Received or Disbursed, include Name of Payee (if Disbursement)

Amount Received

Amount Disbursed

$ Page ____________ of _______ $

$ $

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I state under penalty of perjury that this is a true and complete report of the administration of this estate, during the period shown, both dates inclusive, to the best of my knowledge, information and belief. I understand that this report is subject to audit and verification. I understand that I am required to maintain supporting documentation for all receipts and disbursements including detailed billing statements from any professional. The Court or any Interested Persons as identified in the Order Appointing Conservator may request copies at any time.

Date: ___________________________

_____________________________________________ Signature of Conservator

Date: ____________________________

____________________________________________ Signature of Co-Conservator (if applicable)

Certificate of Service
I certify that on _______________________ (date) the original was e-filed/filed with the Court and a copy of this Conservator's Report was served on each of the following:
Name of Person You are Sending this Document To (Interested Persons) Relationship to Protected Person Address Manner of Service*

*Insert hand delivery, first class U.S. Mail, certified U.S. Mail, E-filed, or Fax.

___________________________________________ Signature of Person Certifying Service

Note:
The Conservator's Report must be filed annually and served on the protected person pursuant to §15-14404(4), C.R.S. and interested persons pursuant to the Order Appointing Conservator, unless otherwise ordered.

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