STATE OF NEBRASKA FORM NO. CC 16:4 3/91 rev.
ANNUAL ACCOUNTING/STATEMENT OF ASSETS
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 ________________, ______.
STATEMENT OF ASSETS
Item $ Value
FORM NO. 16:4 Page 1 of 2
(Certificate of Proof of Possession is required to be attached to this form)
Rec'd from/Paid to
Amount paid or received
(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)