Free Acrobat - South Carolina

STATE OF SOUTH CAROLINA COUNTY OF: IN THE MATTER OF:

) ) ) ) ) )

IN THE PROBATE COURT INVENTORY AND APPRAISEMENT CASE NUMBER:

ORIGINAL SUPPLEMENTAL #

Conservator: The undersigned, being sworn, states: That the following schedules contain a complete and accurate inventory and appraisement of all real and personal property of this estate so far as the undersigned is informed; that he/she has estimated and/or appraised all listed property at its fair market value, according to the best of his/her knowledge and ability. Copies of this inventory have been sent to the following persons:*

SWORN to before me this

day of , 20

Signature: Name: Address: Telephone (O): (H):

Notary Public for South Carolina My Commission Expires:

The gross fair market valuation of all assets, regardless of situs, should be given as of the date of appointment. List all out-ofstate assets on appropriate schedules. A Supplemental Inventory should be utilized for correcting, adjusting, or adding to an original inventory. The type and amount of any encumbrances that may exist with reference to any item should be disclosed. RECAPITULATION Schedule A - Real Estate ..............................................................................................
Schedule B - Investments ..............................................................................................
Schedule C - Anticipated Annual Receipts .........................................................................
Schedule D - Life Insurance ...........................................................................................
Schedule E - Jointly Owned Property ................................................................................
Schedule F - Other Miscellaneous ....................................................................................
Schedule G - Transfers prior to incapacity .........................................................................
Schedule H - Powers of Appointment ...............................................................................
Schedule I - Annuities ..............................................................................................
TOTAL GROSS VALUE ............................................................................................ ENCUMBRANCES ............................................................................................. TOTAL NET WORTH ................................................................................................

$
( $

)

*Within thirty (30) days following appointment, the original inventory shall be filed with the Probate Court. A copy must be provided to the protected person, if he/she has attained the age of 14 years, and to any parent or guardian with whom the protected person resides and to other interested persons as directed by the Court.

FORM #550PC (2/2004) 62-5-418

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NOTE: WHEN COMPLETING THE FOLLOWING SCHEDULES, PLEASE REMEMBER TO LIST ALL ASSETS, REGARDLESS OF SITUS; ALL OUT-OF-STATE ASSETS MUST BE DISCLOSED. SCHEDULE A - Real Estate (If none, so state.) List interest in real property except those held with right of survivorship. (See Schedule E). If real
property is income producing, report income on Schedule C. Item No. Description - Include location, tax map number and use made of property (e.g., rental, owneroccupied) Property, insurance carrier & Amount of Insurance Type of ownership and Percentage Interest (e.g., fee simple, tenants in common) Fair Market value of Protected Person's Interest

TOTAL SCHEDULE A
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$

SCHEDULE B - Investments (If none, so state) List stocks, bonds, notes, receivables, checking and savings accounts, certificates of deposit, mutual
funds, retirement accounts, etc. If investments produce income, report income on Schedule C. List investments held with right of survivorship on Schedule E. Item No. Description of Shares Include kind of investment, location and Type of ownership Fair Market Value number and percentage interest

TOTAL SCHEDULE B
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$

SCHEDULE C - Anticipated Annual Receipts (If none, so state.) List all income, including social security, workers compensation benefits,
annuities, retirement interest income, rental income, alimony, disability benefits, dividends, royalties, etc. Item No. Description When received (monthly, quarterly, annually, etc.) Annual Amount

TOTAL SCHEDULE C

(also enter under recapitulation, page 1)
(If more space is required, insert tax schedules or additional sheets of same size.)
FORM #550PC (2/2004)

$

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SCHEDULE D - Life Insurance owned by the Protected Person. (If none, so state.) Specify type of insurance, e.g., "whole life," "universal life," or
"term." If there are loans against the policy, so indicate. Item No. Description - type, company, name, policy number, premium amount Insured Beneficiary Face Value Cash Value

TOTAL CASH VALUE
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$

Other Insurance - Health, Disability, Supplement, Long Term Care
Item No. Description - type provided Company Name Policy Number Coverage Premium Amount When Payable

SCHEDULE E - Property owned jointly with right of survivorship (if none, so state.)
Item No. Description - include kind, location and co-owner(s) Appraised Value(s) Percentage Ownership Value of Protected Person's Interest

TOTAL SCHEDULE E
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$

(If more space is required, insert tax schedules or additional sheets of same size.)
FORM #550PC (2/2004) Page 3 of 6

SCHEDULE F - Miscellaneous Personal Property - (If none, so state.) List tangible personal property items, title assets, employment bonus or
award, interest in a partnership or unincorporated business, articles or collections having either artistic or intrinsic value, etc.) Item No. Description Location Value of Protected Person's Interest

TOTAL SCHEDULE F

(also enter under recapitulation, page 1)
(If more space is required, insert tax schedules or additional sheets of same size.)

$

SCHEDULE G -Transfers Within Three Years of Incapacity -Transfers intended to take effect at death. United States Government Bonds
"Payable on Death". Trust created by Incapacitated Person prior to incapacity in which income for life was retained. Power to revoke or other incidents of ownership retained, life insurance transfers. Lifetime transfers of real property in which Incapacitated Person retains a life estate or other incidents of ownership. (If none, so state.) Item No. Description Value

TOTAL SCHEDULE G
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$

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(If more space is required, insert tax schedules or additional sheets of same size.)

FORM #550PC (2/2004)

SCHEDULE H - Powers of Appointment - Property, both real and personal, over which Incapacitated Person possesses a Power of Appointment whether Testamentary or otherwise. (If none, so state.) Item No. Description Value

TOTAL SCHEDULE H
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$

SCHEDULE I - Annuities (If none, so state.) (IRA's, Keogh's, etc.)

Item No. Description & Name of Beneficiary Value


TOTAL SCHEDULE I
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$

(If more space is required, insert tax schedules or additional sheets of same size.)
FORM #550PC (2/2004) Page 5 of 6

ENCUMBRANCES - (e.g., mortgages, liens, judgments, etc., but not general debts of the estate) - List specific assets encumbered
Item No. Schedule & Item Number Encumbered Thereby Description & Amount

TOTAL ENCUMBRANCES
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$

(If more space is required, insert tax schedules or additional sheets of same size.)

FORM #550PC (2/2004)

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