Free STATE OF MINNESOTA - Minnesota

M.S. § 524.5-420

State of Minnesota County of __________________

District Court ________________ Judicial District Probate / Mental Health Division Court File No. ___________________ Case Type: 14, Conservatorship

In Re: Conservatorship of ______________________________, Protected Person

_________ ANNUAL ACCOUNT or FINAL ACCOUNT
For Period Ending: _______________ Date of Appointment: _______________

The annual account is summarized on these first two pages. Pursuant to General Rule of Practice for District Courts, Rule 11, restricted identifiers and financial source documents are confidential. See Forms 11.1 and 11.2. Do not list financial account numbers or social security numbers on this form. List such information on Form 11.1.

Assets and Income
1. Beginning Balance: Total Class II property from Inventory for the first annual account, or the balance of personal property assets on hand per the last annual account 2. Other income 3. Social Security 4. Pension /VA Benefits 5. Interest income 6. Dividend income 7. Proceeds from sale of assets 8. Assets omitted from inventory 9. Refunds 10. Other increases

Amount

Deductions and Expenses

Amount

1. Bond premiums 2. Attorney fees 3. Accrued attorney fees 4. Conservator fees 5. Accrued conservator fees 6. Taxes 7. Rent / Mortgage 8. Inventory value of asset sold 9. Other decreases

Total Assets and Income

Total Debts and Deductions ( )

Total Assets and Income Less: Total Debts and Deductions Total Personal Property Assets on Hand: (This should equal the total personal property assets on hand, below)

GAC 14

State

ENG

Rev 5/09-D

www.mncourts.gov/forms

Page 1 of 7

M.S. § 524.5-420

Description of Assets on Hand
Do not list financial account numbers here; list confidential information on Form 11.1 1. Bank Account (include verification form 15-UVF) 2. Stocks (include verification form 15-UVS)

Value

3. 4. 5. 6. 7. Less: accrued attorney fees and accrued conservator fees Total Personal Property Assets on Hand
(This total must match total personal property assets on hand, above)

(

)

1. 2. 3.

Tangible personal property ____ was / ____ was not, disposed of during the year. Real estate ____ was / ____ was not, disposed of during the year. (If real estate is sold during the year you must attach a closing statement to this account) The conservator represents that there is/are on file and in force the following bond(s) (list the name and address of each bonding company and the amount of each bond): ________________________________________________________________________ ________________________________________________________________________ The protected person's current address and phone number is: __________________________ __________________________ __________________________ __________________________ __________________________

4.

5.

CHOOSE ONE OF THE FOLLOWING: The conservator does not request a hearing to examine, settle, and allow this Account. The conservator requests a hearing to examine and, settle, and allow this Account. This is a Final Account and the conservator requests to be discharged from its duties and that the conservator's surety, if any, be discharged.

Note: A hearing is required: *If this is a final account *If it has been five years since the last account was heard and allowed, See Gen.Rul.Prac.Dist.Ct., Rule 416 (but note that Ramsey County and Hennepin County require a hearing after the first annual account and every third year thereafter; also note accounts of $20,000 or less may be waived by the court)

GAC 14

State

ENG

Rev 5/09-D

www.mncourts.gov/forms

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M.S. § 524.5-420

STATE OF MINNESOTA COUNTY OF ___________ I ______________________________ being duly sworn/affirm, under penalties of perjury, say that I have read this account, including the confidential portion therein, that this account is the true and full account of my administration of the estate and of all property belonging to the protected person which has come into my hands or to my knowledge, that I do not know of any error in the account, that I have read the petition and that it is true; and notice to the protected person of the right to petition for restoration to capacity, discharge of conservator, or modification of the orders of conservatorship, has been given to the protected person, and that a copy of the account has been given to the protected person, by _____ MAIL or _____ IN PERSON by ____________________________ (by whom served).

Dated:_____________, 20___

_________________________________ Signature of Conservator Name: ___________________________ Address: ___________________________ ___________________________ ___________________________ Telephone: ___________________________

Subscribed and Sworn to before me this ___________, 20___. _________________________________ Signature of Notary

Name of Petitioner's Attorney: Name: ___________________________ License No.: ___________________________ Address: ___________________________ ___________________________ ___________________________ Telephone: ___________________________

GAC 14

State

ENG

Rev 5/09-D

www.mncourts.gov/forms

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Gen.Rul.Prac.Dist.Ct. Rule 11

State of Minnesota County of _______________

District Court ________________ Judicial District Probate / Mental Health Division Court File No. ___________ Case Type: 14, Conservatorship

In Re: Conservatorship of ______________, Protected Person

CONSERVATORSHIP ACCOUNT FINANCIAL SOURCE DOCUMENT FORM 11.2
(Provided in Accordance With Rule 11 of the Minnesota General Rules of Practice)

THIS LISTING OF SEALED FINANCIAL SOURCE DOCUMENTS IS ACCESSIBLE TO THE PUBLIC BUT THE SOURCE DOCUMENTS SHALL NOT BE ACCESSIBLE TO THE PUBLIC EXCEPT AS AUTHORIZED BY COURT RULE OR ORDER Bank statements Periods covered: Credit card statement Periods covered: Verification of Funds on Deposit Verification of Stocks and Other Securities Other: _______________________________

Information supplied by: ______________________________________ Dated: ____________ Name of Petitioner's Attorney: Name: _____________________ License No.: _____________________ Address: _____________________ _____________________ City/State/Zip: _____________________ Telephone: _____________________

11.2-C

State

ENG

Rev

5/09-D

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Gen.Rul.Prac.Dist.Ct. Rule 11

State of Minnesota County of _______________

District Court ________________ Judicial District Probate / Mental Health Division Court File No. ___________ Case Type: 14, Conservatorship

In Re: Conservatorship of ______________, Protected Person The information on this form is confidential and shall not be placed in a publicly accessible portion of a file.

CONSERVATORSHIP ACCOUNT CONFIDENTIAL INFORMATION FORM 11.1
(Provided in Accordance With Rule 11 of the Minnesota General Rules of Practice)

SOCIAL SECURITY NUMBER NAME BANK ACCOUNT NUMBERS OTHER FINANCIAL ACCOUNT NUMBERS 1. 2. 3. 4. 5. 6. 7. 8. 9. ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________

10. ______________________________________ 11. ______________________________________ 12. ______________________________________ * Add supplemental information if needed

Information supplied by: ______________________________________ Dated: ____________ Name of Petitioner's Attorney: Name: _____________________ License No.: _____________________ Address: _____________________ _____________________ City/State/Zip: _____________________ Telephone: _____________________

11.1-C

State

ENG

Rev

5/09

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Page 5 of 7

M.S. § 524.5-420

State of Minnesota County of _____________________

District Court ________________ Judicial District Probate / Mental Health Division Court File No. ________________________ Case Type: 14, Conservatorship

In Re: Conservatorship of ____________________________, Protected Person

Verification of Funds on Deposit (File as a Financial Source Document with Form 11.2)

Name of Protected Person: _______________________________________ Name and Address of Financial Institution: _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Account Information: Type of Account Account Number Depositor Account Title Interest Earned

Accounts listed below were accurate as of : (mo./day/yr.) ________________________ Current Rate of Interest Current Balance (including interest)

(SEAL OR STAMP OF FINANCIAL INSTITUTION)

I certify that the foregoing amounts were on deposit to the credit of the above named fiduciary as shown by the records of this financial institution. ______________________________________________ TITLE OF CERTIFYING OFFICIAL ______________________________________________ SIGNATURE OF CERTIFYING DATE FINANCIAL INSTITUTION OFFICIAL

15-UVF

State

ENG

Rev

5/09

www.mncourts.gov/forms

Page 6 of 7

M.S. § 524.5-420

State of Minnesota County of ______________________

District Court ________________ Judicial District Probate / Mental Health Division Court File No. __________________________ Case Type: 14, Conservatorship

In Re: Conservatorship of ____________________________, Protected Person

Verification of Stocks and Other Securities (File as a Financial Source Document with Form 11.2)

Name of Protected Person: _______________________________________ Name and Address of Financial Institution: _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ Account Information: Number of Name of Stock or Account Title Units/Shares

Accounts listed below were accurate as of : (mo./day/yr.) ________________________

Remarks:______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
(SEAL OR STAMP OF FINANCIAL INSTITUTION)

I certify that the foregoing amounts were on deposit to the credit of the above named fiduciary as shown by the records of this financial institution. ______________________________________________ TITLE OF CERTIFYING OFFICIAL ______________________________________________ SIGNATURE OF CERTIFYING DATE FINANCIAL INSTITUTION OFFICIAL

15-UVS

State

ENG

Rev 5/09-D

www.mncourts.gov/forms

Page 7 of 7