Free Statement of Financial Resources - West Virginia

IN THE CIRCUIT COURT OF _______________ COUNTY, WEST VIRGINIA
For Clerk's Use Only IN RE: ___________________________________________, DATE FILED: ____________________________________ AN ALLEGED PROTECTED PERSON CASE NUMBER ___________ - G - __________

STATEMENT OF FINANCIAL RESOURCESPORT
[West Virginia Code: § 44A-2-4]
The Petitioner, in any case where the appointment of a conservator is requested, is required to submit a reasonably detailed statement of the financial resources of the alleged Protected Person. This form does not need to be completed or filed if the only relief requested is for the appointment of a guardian. This form must be completed in its entirety and filed with the Clerk of the Circuit Court prior to the hearing to be held on the petition to appoint a conservator. The Petitioner should make a reasonable investigation into the Protected Person's real and personal assets and income, no matter where those assets may be located, and report the findings in this Statement. Attach additional pages as necessary.

1. 2.

ALLEGED PROTECTED PERSON'S SOCIAL SECURITY NUMBER

__________ - _____ - ___________

TO THE EXTENT KNOWN, WHAT IS THE FAIR MARKET VALUE OF THE PROTECTED PERSON'S REAL ESTATE OR REAL PROPERTY? [check whether each parcel of real estate is improved or unimproved and give a brief description of the land (size) and improvements (if any), the location of the parcel (state, county, district), and the fair market value of the parcel] PARCEL 1: Improved? __________ Yes __________ No. Description: __________________________ ______________________________________________________________________________________ Location: ____________________________________________ VALUE $ ________________________ PARCEL 2: Improved? __________ Yes __________ No. Description: ______________________________________________________________________________________ Location: ____________________________________________ VALUE $ ________________________

[Describe any additional parcels on a separate sheet using the format above, then add the values of all parcels and enter the total in the space below.]

COMBINED VALUE OF ALL REAL ESTATE
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VALUE $ ______________________

STATEMENT OF FINANACIAL RESOURCES
SCA-CG-903-1 / 6-00

3.

TO THE EXTENT KNOWN, WHAT IS THE APPROXIMATE VALUE OF ALL THE PROTECTED PERSON'S PERSONAL PROPERTY? [Personal property includes cash on hand or in bank (or other) accounts, stocks, bonds, furniture, automobiles, jewelry, debts due from others (notes/accounts receivable) and other assets not considered to be real estate. List each item or classification of personal property] ITEM(S): _______________________________________________ VALUE $ ______________________ ITEM(S): _______________________________________________ VALUE $ ______________________ ITEM(S): _______________________________________________ VALUE $ ______________________ ITEM(S): ________________________________________________VALUE $ ______________________ ITEM(S): _______________________________________________ VALUE $ ______________________ ITEM(S): _______________________________________________ VALUE $ ______________________ ITEM(S): _______________________________________________ VALUE $ ______________________ ITEM(S): _______________________________________________ VALUE $ ______________________ ITEM(S): _______________________________________________ VALUE $ ______________________

[Describe any additional personal property on a separate sheet using the format above, then add the values of all the listed items and enter the total in the space below.] COMBINED VALUE OF ALL ITEMS OF PERSONAL PROPERTY VALUE $ ___________________

4. TO EXTENT KNOWN, WHAT IS THE ANTICIPATED ANNUAL GROSS INCOME OR OTHER RECEIPTS OF THE
PROTECTED PERSON? [List each source of income and the anticipated annual amount of income from that source]

SOURCE: _____________________________________ SOURCE: _____________________________________ SOURCE: _____________________________________

ANNUAL INCOME: $ ______________________ ANNUAL INCOME: $ ______________________ ANNUAL INCOME: $ ______________________

[List any additional sources of annual income on a separate sheet using the format above, then add the incomefrom all sources and enter the total in the space below.] TOTAL ANNUAL INCOME FROM ALL SOURCES: $ ______________________

STATEMENT OF FINANACIAL RESOURCES
SCA-CG-903-2 / 6-00

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5. SUMMARY OF ASSETS & ANNUAL INCOME
COMBINED VALUE OF ALL REAL ESTATE (Question 2 total) $ ____________________ COMBINED VALUE OF ALL ITEMS OF PERSONAL PROPERTY (Question 3 total) + $ __________________

TOTAL ALL ASSETS (Real Property + Personal Property)

$ __________________

TOTAL ANNUAL INCOME FROM ALL SOURCES

$ __________________

I, ____________________________________, the Petitioner in the foregoing matter, hereby certify that I have conducted a reasonable investigation into the assets and income of the alleged protected person named in this Statement, that the foregoing Statement of Financial Resources is true, complete and correct to the best of my knowledge, information and belief, that I have included within the foregoing Statement, and any and all attachments thereto, all items of real property, personal property and all sources of income of the alleged protected person which are known, or have been disclosed, to me.

Given under my hand this ________ day of _______________________, 20________.

________________________________________________ PETITIONER'S SIGNATURE

STATEMENT OF FINANACIAL RESOURCES
SCA-CG-903-23/ 6-00

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