Free Annual Accounting/Statement of Assets, CC 16:4 - Nebraska

STATE OF NEBRASKA FORM NO. CC 16:4 3/91 rev.

ANNUAL ACCOUNTING/STATEMENT OF ASSETS
Beginning_____________ Ending_________________

CASE NUMBER

IN THE MATTER OF THE GUARDIANSHIP/CONSERVATORSHIP OF

ANNUAL ACCOUNTING/ STATEMENT OF ASSETS
(Ward) STATE OF NEBRASKA COUNTY OF ) ) ss. )

The undersigned Guardian/Conservator of person and property of the above named ward, being duly sworn, says this account is in all respects just and true, and that to the best of her/his knowledge and belief she/he has accounted for all the property of the ward that has come into her/his possession or knowledge, or the possession for anyone of her/him for said ward. DATE: GUARDIAN/CONSERVATOR: Address:

Phone: Subscribed and sworn to before me on this ________ day of ________________, ______.

(Notary Public)

STATEMENT OF ASSETS
Item $ Value

TOTAL:
FORM NO. 16:4 Page 1 of 2

$

(Certificate of Proof of Possession is required to be attached to this form)

CASE NUMBER_______________________
______________________________________ (Ward)
Beginning Balance

Date

Check No.

Rec'd from/Paid to

Purpose

Amount paid or received

Balance

(Attach additional sheets if necessary)
FORM NO. 16:4 Page 2 of 2 (Certificate of Proof of Possession is required to be attached to this form)

Ending Balance