State of Minnesota County of __________________ District Court ________________ Judicial District Probate / Mental Health Division Court File No. ___________________ Case Type: 14, Conservatorship In Re: Conservatorship of INVENTORY ______________________________, Protected Person Date of Appointment: _______________ The Inventory is summarized on these pages. Pursuant to General Rule of Practice for District Courts, Rule 11, restricted identifiers and financial source documents are confidential. See Forms 11.1 and 11.2. Do not list financial account numbers or social security numbers on this form. List such information on Form 11.1. CLASS I PROPERTY: Real Estate Real Estate Specify plat or survey description. Specify encumbrances, liens, etc., and respective sums for each. a. Homestead: located in the County of ______________; Legally described as: Amount Total b. Non-homestead real property: located in the County of ___________, legally described as: Total Class I Property: Real Estate GAC 13 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com CLASS II PROPERTY: Personal Property a. Furniture and Household Goods (attach statement if needed) 1. 2. 3. 4. a. Total Furniture, Fixtures and Household Goods: b. Wearing Apparel (attach statement if needed) 1. 2. 3. 4. b. Total Wearing Apparel: c. Corporate Stocks (attach statement if needed) Corporate name, number of shares and value per share Amount Total Amount Total Amount Total 1. 2. 3. 4. c. Total Corporate Stock: d. Bank Accounts ­ Certificates of Deposit (attach statement if needed) Specify Institutions and Balances ­ List Account Numbers on Confidential Form 11.1 Amount Total 1. 2. 3. 4. d. Total Bank Accounts and Certificates of Deposit: Other Personal Property (attach statement if needed) 1. Attach statement if needed 2. 3. 4. e. Total Other Personal property: Amount Total Total Class II Property: Personal Property Subtotal of Class II items: a, b, c, d and e (List this amount on Line 1 of the First Annual Account, Form 14) GAC 13 State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Total Real and Personal Property Total Class I Property: Real Estate Total Class II Property: Personal Property Total Class I and Class II Property STATE OF MINNESOTA COUNTY OF ___________ ______________________________ hereby states that s/he is the conservator of the estate for the above-entitled protected person, that s/he has read the inventory and knows its contents, including the confidential provisions herein, that the same is a true and correct Inventory of the protected person's estate that has come into the conservator's possession, and that s/he has given notice of the filing of this inventory, together with a copy of the inventory, to the protected person. I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. § 358.116. Dated: _____________, 20___ Signature of Conservator Name: Address: Telephone: E-mail address Name of Petitioner's Attorney: Name: License No.: Address: Telephone: E-mail address GAC 13 State ENG Rev 7/15 www.mncourts.gov/forms Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com State of Minnesota County of _______________ District Court ________________ Judicial District Probate / Mental Health Division Court File No. ___________ Case Type: 14, Conservatorship In Re: Conservatorship of ______________, Protected Person CONSERVATORSHIP ACCOUNT CONFIDENTIAL FINANCIAL SOURCE DOCUMENTS (also known as Form 11.2) (Minn. Gen. R. Prac. 11.02) THIS LISTING OF SEALED FINANCIAL SOURCE DOCUMENTS IS ACCESSIBLE TO THE PUBLIC BUT THE SOURCE DOCUMENTS SHALL NOT BE ACCESSIBLE TO THE PUBLIC EXCEPT AS AUTHORIZED BY COURT RULE OR ORDER Bank statements Periods covered: Credit card statement Periods covered: Verification of Funds on Deposit Verification of Stocks and Other Securities Other: _______________________________ Information supplied by: Dated: ____________ Name of Petitioner's Attorney: Name: License No.: Address: City/State/Zip: Telephone: E-mail address GAC 16 State ENG Rev 7/15 www.mncourts.gov/forms Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com State of Minnesota County of _______________ District Court ________________ Judicial District Probate / Mental Health Division Court File No. ___________ Case Type: 14, Conservatorship In Re: Conservatorship of ______________, Protected Person The information on this form is confidential and shall not be placed in a publicly accessible portion of a file. CONSERVATORSHIP ACCOUNT CONFIDENTIAL INFORMATION FORM 11.1 (also known as Form 11.1) Minn. Gen. R. Prac. 11.02 SOCIAL SECURITY NUMBER NAME BANK ACCOUNT NUMBERS OTHER FINANCIAL ACCOUNT NUMBERS 1. 2. 3. 4. 5. 6. 7. 8. 9. ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ ______________________________________________________ 10. ______________________________________ 11. ______________________________________ 12. ______________________________________ * Add supplemental information if needed Information supplied by: Dated: ____________ Name of Petitioner's Attorney: Name: License No.: Address: City/State/Zip: Telephone: E-mail address GAC 15 State ENG Rev 7/15 www.mncourts.gov/forms Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com