Rule 7.11 -- Form 5: Final Report of Conservator If filing electronically, you must provide any protected information in full on form 6, according to Division VI of Chapter 16 of the Iowa Court Rules. If filing in paper, you may use form 6 to provide any protected information in full. In the Iowa District Court for In the Matter of the Conservatorship of: Probate no. County Final Report of Conservator Full name: first, middle, last If the Ward is a minor, use initials only Ward. 1. This Final Report is for the period from: Use ending date of last accounting when applicable / Month Day / Year to / Month Day / Year 2. 3. 4. 5. 6. Total cash on hand at close of the last accounting: Total sum of funds received during this report period: Total sum of disbursements made during this report period: Balance of cash on hand at the close of this report period: Other assets of the Ward at the close of this Final Report. $ $ $ $ . . . . Include as attachment "A" an itemization showing date received, source of funds, and amount. Include as attachment "B" an itemization showing date, who was paid, and amount paid for item or service. Include a listing of assets held and the value or remaining balances as attachment "C." If assets remained the same from the last report, a copy of the last listing may be used. 7. 8. Were changes made in investment during this report period? Yes Include as attachment "D" an itemized list of changes when applicable. No The total value of assets of the Ward at the close of this report period: $ . 9. Termination: Include as attachment "E" a statement of reasons for termination. Check one A. B. The court on the day of , 20 , ordered termination. Termination is concurrently sought with approval of final report. 10. On termination, funds and assets of this conservatorship will be distributed, if any, to the following: Full name: first, middle, last If waived, attach copy of waiver. Relationship to Ward No 11. Has notice of hearing on Final Report been waived? Yes 12. Amount of Conservator's bond: $ . Surety is: . Company providing bond Order approving final report and termination should discharge surety and release bond. May 2014 Rule 7.11 -- Form 5 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Rule 7.11 -- Form 5: Final Report of Conservator, Continued 13. Guardian Check one A. The Conservator is also the Guardian and has filed a Final Report of Guardian on , 20 Month Day Year . B. C. The name of the Ward's Guardian is: Full Name: first, middle, last The Ward has no Guardian. If you check C, you must fill in the following information. (1) The residence and physical location of Ward: Street Address City State ZIP code (2) General physical and mental condition of Ward: 14. Other information relating to affairs of the conservatorship: If conservatorship has special circumstances that do not adapt to this form, include attachment "F," setting out special circumstances in detail. 15. Have final court costs been paid? Yes Attach Affidavit per Iowa Code section 633.202. No waived. 16. Fees for Conservator are: hereby applied for 17. Fees for Conservator's attorney: Check one A. B. should be set by the court. are not requested. C. are waived or not applicable. Attach Affidavit per Iowa Code section 633.202, if fees requested. 18. Receipt(s) of the distributee(s) for the funds and assets of the conservatorship: Check one A. B. are attached. will be attached to supplemental report after court approves Final Report. 19. Oath and Signature I, Print Conservator's name , have read this Final Report, and I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the information I have provided in this Final Report is true and correct. , 20 Month Day Year Conservator's signature* Mailing address City State ZIP code ( ). Phone number Email address Additional email address, if applicable * Whether filing electronically or in paper, you must handwrite your signature on this form. If you are filing electronically, scan the form after signing it and then file electronically. Note: Bank statements, checks, receipts, stubs, and other items evidencing receipt of funds and payment must be available to the court on demand. May 2014 Rule 7.11 -- Form 5 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com