Free GUARDIANSHIP ANNUAL REPORT - Alaska

IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Protective Proceedings of: ) ) ) (Name of Protected Person) ) ) Date of Birth: ) ) ) Residential location of Protected Person: ) ) Protected Person's Telephone #: ) )

CASE NO. FINAL CONSERVATORSHIP REPORT

Instructions To Conservator
Please type or print clearly using black ink. In preparing the report, you must consult with the protected person as much as possible (if the protected person is still living). The court will treat the information in this report as confidential. If you are unable to complete this form without help, you may find assistance on the website of the Office of Public Advocacy (OPA): www.state.ak.us/guardianship. Your local library and court may also have a binder of helpful information entitled "Family Guardian Education Materials," prepared by the Alaska State Association for Guardianship and Advocacy. You may also call OPA at 269-3500 (in Anchorage), 451-5933 (in Fairbanks) or 1-877-957-3500. After completing this report, you must sign it under oath (or affirmation) in the presence of a notary public or court clerk. See last page. The purpose of this report is to tell the court why your service as conservator is ending and what has happened to the protected person and the protected person's assets since you filed your last annual report. Reporting Period This report covers the period: From the end of the last reporting period: To the date my services as conservator ended: Information About Conservator Conservator's Name Mailing Address (box or street number) Check here if this mailing address is new. Relationship to protected person: Was a separate guardian appointed for the person?
Page 1 of 11 PG-230 (2/05)(cs) FINAL CONSERVATORSHIP REPORT

Daytime Phone (city) (state) (ZIP)

No

Yes Name:
Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100

Reason For Ending Conservatorship My conservatorship of the protected person has ended because: The protected person died on
date)

at
(location)

A copy of the death certificate is attached. I did did not have possession of the protected person's will. On , 20 , I delivered the protected person's will to the court for safekeeping, as required by AS 13.26.285(e), and informed the executor or a beneficiary named in the will that the will had been so delivered. Name of person notified: , has been appointed.
(name)

I resigned as conservator. A new conservator, I was removed by the court. The court has terminated the conservatorship because

Other (Explain):

If the protected person is deceased or if the conservatorship has been terminated because the protected person regained the ability to manage his/her property and affairs, you need not fill out paragraphs 1-6. Skip to paragraphs 7 - 16.
Information About Protected Person 1. Housing. Where does the protected person live now (name of facility or place)? Who takes care of the protected person? nursing home Type of Residence: 2. Medical Care. a. Describe in general terms the nature of the protected person's medical expenses during the reporting period (services received and cost).

assisted living home

b.

Has there been a significant change in these expenses from the prior year? Yes No Explain:
Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100

Page 2 of 11 PG-230 (2/05)(cs) FINAL CONSERVATORSHIP REPORT

3.

School and Job Training. Since the last report to the court, did the protected person attend school or receive any No Yes. Describe studies (include name and location of type of job training? school): Cost:

4.

Work. Was the protected person employed at any time during the period since the last report to the court? No Yes. Describe (include type of work, name of employer, address, phone, and how long employed):

5.

Contacts With Protected Person. Describe your contacts with the protected person in the period since your last report to the court: Type of Contact How Often in person by telephone by mail or e-mail through 3rd person: other:

6.

Decision Making. Have there been any changes in the protected person's ability to make decisions on financial matters?

7.

Significant Actions. Describe any significant actions you took as conservator for the protected person during the period since your last report was filed with the court (including any actions taken regarding the protected property and funds):

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Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100

8.

Additional Information. List any additional information about the protected person that you wish to report to the court:

9.

Protected Person's Income Since Last Annual Report. (List only the income of the protected person. Do not list your income.) Amount Received Since Last Income Source Annual Report Social Security Benefits: a. SSA: b. SSI: Adult Public Assistance: Veterans Financial Benefits: Alaska Longevity Bonus: Permanent Fund Dividend: Native Corporation Dividend: Wages: Dividends/Interest: Rental Income: Pension: Annuities: Other (describe):

Total Income Received Since Last Annual Report:

$0.00

Page 4 of 11 PG-230 (2/05)(cs) FINAL CONSERVATORSHIP REPORT

Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100

10.

Protected Person's Expenses Since Last Annual Report. (Money paid to anyone on behalf of protected person or his/her legal dependents. Do not include your personal expenses. Attach extra pages if necessary.) Amount Spent Since Last Description Annual Report Expense Nursing/ Assisted Living Home: Rent Payment: Mortgage Payment: Utilities: Transportation: Medical Treatment Costs: Medications: Credit Card Payments: Food: Clothing: Recreation or Entertainment: Personal Expenses (include allowance): Income Tax/Property Tax: Home/Property Maintenance Costs: Insurance Home Insurance: Auto Insurance: Medical Insurance: Life Insurance: Gifts: Child/Spousal Support: Fees/Costs Paid to Conservator: Burial Expenses: Other (list all other payments made):
$0.00

Total Expenses Since the Last Annual Report: 11. Money Controlled By Protected Person.

Since the last annual report was filed, did the protected person have sole control over any money? Yes No If yes, please explain: Is this money included in the income and expenses listed in #9 and #10? Explain: Yes No

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Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100

12.

Protected Person's Assets on the following date: . (List all assets the person owned individually or jointly. Attach extra pages if necessary.) a. Cash on hand (not in an account) $ (amount) Explain any changes since last report: b. Burial Account Name of Bank or Institution Type of Account Account Number Balance (where located)

Explain any changes since last report: c. Alaska Native Corporation Dividend Account Name of Bank or Institution Type of Account Account Number Balance

Explain any changes since last report: d. List all other bank accounts, certificates of deposit, etc. Attach the most recent bank statement. Attach additional pages if necessary. Name of Bank or Institution Name(s) on Account Account Number Balance

Explain any changes since last report:

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Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100

e.

List all Brokerage Accounts, Stocks, Bonds, and Other Securities. Attach the most recent account statement. Attach additional pages if necessary. Name of Company Name(s) on Account Account Value on (date)

Explain any changes since last report: f. Retirement Accounts. Name of Company Beneficiary Current Value

Explain any changes since last report: g. Life Insurance Policies (policies the protected person owns). Name of Company Beneficiary of Life Insurance Face Value of Life Insurance Cash Value of Life Ins.

Explain any changes since last report: h. Real Estate that Protected Person Owns (land and buildings). Attach tax assessment, if available. (1) Does person own a home? No Yes. Estimated Value:$ Address: Description: Is there a joint owner? No Yes Explain any changes since last report:
Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100

Page 7 of 11 PG-230 (2/05)(cs) FINAL CONSERVATORSHIP REPORT

(2)

Other Real Estate. Estimated Value: $ Address: Description: Is there a joint owner? No Yes Explain any changes since last report:

i.

Vehicles. (List any cars, boats, snow machines, off-road vehicles, airplanes, etc.) Type of Vehicle Year, Make & Model Value Co-Owner

Explain any changes since last report:

j.

Furniture, Appliances and Electronic Equipment exceeding $400 in Value. Attach additional pages if necessary. Description of Item Approximate Age Value

Explain any changes since last report:

k.

Jewelry, Gems, Precious Metals, Coin or Stamp Collections, Other Collections, Artwork, Raw or Decorated Ivory. Attach additional pages if necessary. Description of Item Location Value

Explain any changes since last report:

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Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100

l.

Other Personal Property. (List any item that has a value over $400. Please include any collectibles and any other items that are particularly susceptible to theft. Give details sufficient to allow a third party to identify the item. Attach extra pages, if necessary.) Location Value Description of Item

Explain any changes since last report: m. Commercial Fisheries Interests (IFQs or limited entry permits). Value

Explain any changes since last report: TOTAL ASSETS (Total value of all items in #12 a through m) Total Assets at End of Previous Reporting Period: Change in Total Assets Since Previous Reporting Period: 13. Protected Person's Liabilities as of $ $ $
0.00 0.00

. (date) (List all debts the protected person owes. Attach extra pages if necessary.) Real Estate Debts. (1) Home described in #12(h)(1). Loan balance: $ Explain any changes since last report:

a.

(2) Property described in #12(h)(2). Description: Loan balance: $ Explain any changes since last report: b. Other Loans. Lender (Name & Address)

Purpose (loan type) Loan Number Balance Due

Explain any changes since last report:

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Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100

c.

Credit Cards. Company (Name & Address)

Card

Card Number

Balance Due

Explain any changes since last report:

d.

Judgments/liens.

Description

Balance Due

Explain any changes since last report:

e.

Amounts Owed For Services. Service (1) Medical Services (2) Attorney Services (3) Conservator Services (4) Other Explain any changes since last report:

To Whom Owed

Balance Due

TOTAL LIABILITIES (Total all items in #13 a through e): Total Liabilities at End of Previous Reporting Period: Change in Total Liabilities Since Previous Reporting Period: 14. NET ASSETS (Subtract Total Liabilities from Total Assets): Total Assets from 12 a - m Total Liabilities from 13 a - e Net Estate Value Net Assets at End of Previous Reporting Period: Change in Net Assets Since Previous Reporting Period: 15.

$ $ $

0.00
0.00

$ $ $ $ $

0.00 0.00 0.00
$0.00

Trusts. The protected person is a beneficiary of the following trust(s) (meaning the person has the right to receive benefits of some kind from the trust): Name of Trust: Name and Address of Trustee: If registered with the court, list trust registration no. State Do you know what benefits the protected person is supposed to receive from the trust? Yes No Is the protected person receiving the benefits from the trust that he/she is supposed to Yes No I do not know. receive? Explain any changes since last report:

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Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100

16.

Assets Released. The protected person's assets were released as follows: To Whom Released Asset Released Date (Name and Address)

Authority of Person To Receive This Property *

* For authority, list recipient's role, such as former protected person, new conservator,
personal representative of deceased person's estate, special administrator, temporary property custodian or heir. Oath I do solemnly swear (or affirm) that the information given in this report is true and correct to the best of my knowledge and belief. Date Subscribed and sworn to or affirmed before me at on , 20 . (SEAL) Conservator's Signature , Alaska

Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires:

, I certify that on I gave a copy of this report and its attachments to: protected person protected person's attorney or guardian ad litem (if currently representing protected person): parent or guardian with whom protected person resides (if any): protected person's guardian (if a separate guardian was appointed): the following person(s) designated by court order:

Conservator's Signature

Page 11 of 11 PG-230 (2/05)(cs) FINAL CONSERVATORSHIP REPORT

Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100