Free Annual or Biennial Account and Report of Conservator and Petition for Approval of Account and Report (PR-E - California

PR-E-LP-027

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ATTORNEY'S NAME OR PETITIONER IN PRO PER ATTORNEY'S BAR NUMBER: STREET ADDRESS: CITY, STATE, ZIP CODE: TELEPHONE NUMBER: EMAIL: FAX:

IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA IN AND FOR THE COUNTY OF SACRAMENTO No. In re: Conservatorship of the ( ) Person and ( ) Estate of: _____________________, Conservatee (state name) ( ) ____________ ANNUAL OR (1st, 2nd, 3rd , etc) ( ) ____________ BIENNIAL
(1ST, 2ND, 3RD , etc.)

Dept. 129

ACCOUNT AND REPORT OF CONSERVATOR AND PETITION FOR APPROVAL OF ACCOUNT AND REPORT, ( ) AND FOR APPROVAL OF CONSERVATOR'S FEES ( ) AND ATTORNEY'S FEES ( ) OTHER (State):
Hearing Date: Time: Calendar No.:

Petitioner, ___________________, respectfully represents:
(Name)

1. Appointment. On __________, Petitioner was appointed as
(Date)

Conservator of the person/estate of ____________________. The Letters of
(Name)

Administration were issued on _________. At all times since the appointment, (Date) Petitioner has been acting as the Conservator. 2. The conservatee currently resides at: 3. Period of Account. The account and report covers the period beginning ______________, and ending _______________.
(Date) (Date)

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4. Inventory and Appraisement. The Inventory and Appraisement was filed on: __________, showing the value of the estate to be: $ __________.
(Date)

Supplemental Inventory and Appraisements was filed on: __________, stating the value of assets to be: $ ___________. 5. Account Petitioner is chargeable and is entitled to credits, respectively, as set forth in attached "Exhibit "1", summary of account, and supporting schedules. 5a. Financial Account Statements. Note: The conservator must attach an original account statement stating value for any asset held at close of this accounting period from the following type of financial institution: insurance company, broker or agent, investment company or bank, securities broker-dealer, investment advisor or financial planner, bank trust, savings and loan, industrial bank or credit union. Check the applicable box: ( ) Petitioner has attached the required financial institution statements on Exhibit "2". ( ) Petitioner has filed herewith a separate affidavit captioned "Confidential Financial Statement" with attached financial institution statements containing confidential information. 6. Interest Bearing Accounts. (If applicable, check the box) ( ) All the cash was invested and maintained in interest bearing accounts or in investments authorized by law or the governing instrument, except for an account of cash that was reasonably necessary for the orderly administration of the estate. 7. Sales, Purchases, Change in form of assets. During the period of this report; sales, purchases or change in form of assets ( ) did ( ) did not occur. If in the affirmative, describe the transactions.

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 OPTIONAL PR-E-LP-027 (1.1.07) -3Account and Report of Conservator LOCAL RULE 15.86 10. Liabilities of the Estate. There ( ) are ( ) are not any outstanding debts (includes tax due, notes payable, court judgments) at the end of the accounting period. If in the affirmative, describe the debts, date of creditor claim, amount owed, terms: 9. Income from Business or Trade. There ( ) was ( ) was not any income or loss from a trade or business. If in the affirmative, describe. 8. Unusual Items in the Account. There ( ) were ( ) were not unusual items in the accounting requiring explanation. If in the affirmative, describe the transactions.

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11. Bond Report. Fair Market, Value of Assets (do not include real property) : $ ___________ Annual Income or Receipts from all sources: Total Bondable Estate: $ ___________ $ ___________

Current Bond:

$ ___________

Current Assets in Blocked Account: $ ___________ Total: $ ___________

Petitioner requests: ( ) Additional Bond: $ ______________

( ) Reduction in Bond: $ ______________ ( ) No change in amount of bond. ( ) Additional assets be ordered blocked as follows (state amount, financial institution): 12. Family or Affiliate Relationship. There ( ) is ( ) is not any family or affiliate relationships between the fiduciary and any agent hired by the fiduciary during the accounting period. If in the affirmative, describe.

13. Veteran's Administration. The conservatee ( ) is ( ) is not entitled to receive Veteran's Administration Benefits.

14. State Hospital. The conservatee ( ) was ( ) was not a patient on leave of absence from a state hospital.

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15. Person Entitled to Notice. A request for Special Notice ( ) has ( ) has not been filed. If in the affirmative list name and address of person (1) requesting Special Notice: Name Address Adult/Minor Relationship

List all persons entitled to notice of the hearing on the petition, state name, address, & relationship to conservatee. Name Address Adult/Minor Relationship

16. Conservator Fees and Costs. Petitioner requests fees as follows: ( ) Fees are waived or ( ) Not requested at this time. ( ) Fees are requested in the amount of $ ____________ Itemization of services set forth by date, time spent, & hourly rate are set forth in Exhibit "3". (Note: Exhibit "3" must include a statement of facts which must (1) show the nature and difficulty of tasks performed; (2) show the results achieved; (3) show the benefit of the services to the estate; (4) specify the amount requested for each category of service performed; (5) state the hourly rate of each person who performed services and the hours spent by each of them; (6) describe the services rendered in sufficient detail to demonstrate the productivity of the time spent. Petitioner requests: ( ) No Conservator Costs/Expenses OPTIONAL PR-E-LP-027 (1.1.07) -5Account and Report of Conservator LOCAL RULE 15.86

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( ) Conservator Costs/Expenses advanced in the sum of $ ____________ be reimbursed. Itemization by date, amount, and purpose is set forth in Exhibit "3". 20. Attorney Fees and Costs. (Note: Attorney must attach a separate verification in support of fees being requested) Petitioner requests attorney fees be approved as follows: ( ) Fees are waived or ( ) Not requested at this time. ( ) Fees are requested in the amount of $ ___________. Itemization of services set forth by date, time spent, & hourly rate are set forth in Exhibit "4". (Note: Exhibit "4" must include a statement of facts which must (1) show the nature and difficulty of tasks performed; (2) show the results achieved; (3) show the benefit of the services to the estate; (4) specify the amount requested for each category of service performed; (5) state the hourly rate of each person who performed services and the hours spent by each of them; (6) describe the services rendered in sufficient detail to demonstrate the productivity of the time spent. If the attorney fees requested include a paralegal acting under the direction and supervision of an attorney, then set forth in Exhibit 4 the following information: (1) Describe the qualifications of the paralegal (including education, certification, continuing education, and experience); (2) state the hours spent by the paralegal and the hourly rate requested for the paralegal's services; (3) describe the services performed by the paralegal; (4) state why it was appropriate to use the paralegal's services in the particular case; (5) demonstrate that the total amount requested for the extraordinary services of the attorney and the paralegal does not exceed the amount appropriate if the attorney had performed the services without the paralegal's assistance. Petitioner requests: ( ) No Attorney Costs/Expenses ( ) Attorney Costs/Expenses advanced in the sum of $ ____________ be reimbursed. Itemization by date, amount, and purpose is set forth in Exhibit "4". OPTIONAL PR-E-LP-027 (1.1.07) -6Account and Report of Conservator LOCAL RULE 15.86

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21. Compensation Paid from Conservatorship Estate to the Conservator or Attorney for Conservator without prior court order (Check applicable box): ( ) Conservator compensation ( ) was ( ) was not paid. ( ) Attorney fees ( ) were ( ) were not paid. If compensation or fees were paid, state: Date Amount To Whom Paid

22. Other (Add any additional information or actions by the conservator to be included in the report for which court approval is requested:

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WHEREFORE, petitioner requests that: 1. The within account and report be settled, allowed, and approved; 2. All acts and transactions as set forth in the account and report be approved; 3. The conservatorship be terminated. 4. Petitioner be authorized and directed to pay from the conservatorship estate to: ( ) petitioner the sum of $ ________ as compensation for conservator services rendered; ( ) petitioner costs advanced in the sum of $____________ during the period of this account; ( ) attorney ______________ the sum of $ ________ as compensation for (Name) legal services rendered; ( ) attorney ______________ costs advanced in the sum of $____________ during
(Name)

account. 5. Bond be ( ) Reduced to: $__________. ( ) Additional Bond of $_________ be posted for a total bond of $__________. 6. Other (include additional requests not included above): 7. For other orders as the court may deem proper. DATED: __________________________________________ Signature

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 OPTIONAL PR-E-LP-027 (1.1.07) -9Account and Report of Conservator LOCAL RULE 15.86 Sacramento, California. ________________________
(Signature)

VERIFICATION I, ___________________ declare:
(Petitioner Name)

I am the petitioner herein. I have read the foregoing account, report, and petition and the accompanying exhibits and schedules and know the contents and the same is true of my own knowledge except as to those matters which are therein stated upon my information and belief, and, as to those matters, I believe it to be true. The account contains a full statement of all charges against me and of all credits to which I am entitled on account of the estate during the period embraced in the account. Each item of expenditure therein set forth was actually paid out at the time and place and to the person as therein specifically state. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct and that this verification was executed on ________, at
(Date)

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 OPTIONAL PR-E-LP-027 (1.1.07) TOTAL CREDITS: CREDITS:_ Disbursements (Schedule D) Losses on Sale or Other Disposition (Schedule E) Net loss from trade or business (Schedule F) Distributions (Schedule G) Property on hand at close of account (Schedule H) TOTAL CHARGES CHARGES:

EXHIBIT "1" SUMMARY OF ACCOUNT

Property on hand at beginning of account (or Inventories) Additional property received (or Supplemental Inventories) Receipts (Schedule A) Gains on Sale or Other Disposition (Schedule B) Net Income from trade or business (Schedule C)

$__________

__________ __________

__________

__________

*$__________ ________

$__________ __________ __________ __________ __________

*$__________

*Total Charges should equal Total Credits

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1 2 3 4 5 6 7 8 9 10 Retirement Income 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 OPTIONAL PR-E-LP-027 (1.1.07) Dividend Income Interest Income Social Security DATE

SCHEDULE A RECEIPTS

PAYEE AND PURPOSE

AMOUNT

TOTAL: __________________

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1 2 3 4 5 6 7 8 9 10 Other Receipts 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 OPTIONAL PR-E-LP-027 (1.1.07) Rental Income DATE

SCHEDULE A RECEIPTS

PAYEE AND PURPOSE

AMOUNT

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SCHEDULE B GAIN ON SALE OR OTHER DISPOSITION

Description of Property

Sales Price

Inventory Value

Gain on Sale

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SCHEDULE D DISBURSEMENTS

PAYEE AND PURPOSE

AMOUNT

Housing (Mortgage/Rent)

$

In-Home/Resident Care 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 OPTIONAL PR-E-LP-027 (1.1.07) -14Account and Report of Conservator LOCAL RULE 15.86 TOTAL: __________________ Medication & Medical Supplies

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1 2 3 4 5 6 7 8 9 10 Utilities 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 Telephone Food DATE

SCHEDULE D DISBURSEMENTS

PAYEE AND PURPOSE

AMOUNT

Credit Cards/Finance Co.

TOTAL: __________________ 28 OPTIONAL PR-E-LP-027 (1.1.07) -15Account and Report of Conservator LOCAL RULE 15.86

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 OPTIONAL PR-E-LP-027 (1.1.07) Bond Premiums Bank Fees DATE

SCHEDULE D DISBURSEMENTS

PAYEE AND PURPOSE

AMOUNT

Repairs & Maintenance

Insurance Premiums

TOTAL: __________________

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 TOTAL: __________________ 28 OPTIONAL PR-E-LP-027 (1.1.07) -17Account and Report of Conservator LOCAL RULE 15.86 Miscellaneous Disbursements Administration Expenses & Fees Taxes Accounting & tax Service Fees DATE PAYEE AND PURPOSE AMOUNT SCHEDULE D DISBURSEMENTS

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SCHEDULE E LOSS ON SALE OR OTHER DISPOSITION

Description of Property

Sales Price

Inventory Value

Gain on Sale

TOTAL: __________________ 28 OPTIONAL PR-E-LP-027 (1.1.07) -18Account and Report of Conservator LOCAL RULE 15.86

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SCHEDULE G DISTRIBUTIONS

Address

Relationship

Item Distributed

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 2. Real Property ( ) None 1. Bank/Credit Union Accounts

SCHEDULE H PROPERTY ON HAND Current Fair *Carry Value xxxxxxxx xxxxxxxx xxxxxxxx xxxxxxxx xxxxxxxx xxxxxxxx Market Value

(such as checking, savings, money markets, certificate of deposit) (state name of financial institution, account number, & amount of hand at end date of account period)

( ) Listed below (state common street address, legal description, how title is held, and interest held by the conservatee)

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 5. Furniture & Personal Effects:

SCHEDULE H PROPERTY ON HAND *Carry Value Current Fair Market Value 3. Stocks & Bonds: (List name of stock or identify the bond, # of shares, and value at end date of account)

4. Automobile (state year, make, and model)

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SCHEDULE H PROPERTY ON HAND *Carry Value Current Fair Market Value

TOTAL:

$__________

$__________

*(value stated from last acct or if no acct from Inventory & Appraisal) 28 OPTIONAL PR-E-LP-027 (1.1.07) -22Account and Report of Conservator LOCAL RULE 15.86