Nebraska State Court Form REQUIRED PERSONAL AND FINANCIAL INFORMATION FOR GUARDIANSHIPS AND CONSERVATORSHIPS Ch.6, Art.14, App. 11 Rev. 03/2017 Neb. Ct. R. § 6-1464(B) TO THE GUARDIAN AND/OR CONSERVATOR: This form is to be filed only with the Court. Do not send this form to interested persons. Fill out one form for each ward, incapacitated person or protected person. IN THE COUNTY COURT OF________________COUNTY, NEBRASKA THIS DOCUMENT IS CONFIDENTIAL AND SHALL NOT BE MADE PART OF THE COURT FILE OR PROVIDED TO THE PUBLIC PURSUANT TO NEB. CT. R. § 6-1464. Case Number: ________________ IN THE MATTER OF Ward/Incapacitated Person/Protected Person CONFIDENTIAL PERSONAL AND FINANCIAL INFORMATION FOR GUARDIANSHIPS AND CONSERVATORSHIPS Full Social Security number of the ward, protected or incapacitated person: Full name of the ward, protected or incapacitated person: Full date of birth of the ward, protected or incapacitated person: FINANCIAL INFORMATION OF THE WARD, PROTECTED OR INCAPACITATED PERSON Name(s) and address(es) of financial institution(s) Full account number(s) _________________________________________ __ Signature(s) ____________________________________________________ Name(s) ____________________________________________________ Bar Number and Firm Name (attorneys only) _____________________ Phone Date ___________________________ ___ ___________________________________________________ Street Address/P.O. Box Number ___________________________________________________ City/State/ZIP Code ___________________ E-mail Address __________ ___ Instructions: When parties are required to report personal and financial information to the court, the complete information shall be provided on Appendix 11. On pleadings or documents to be filed with the court, financial account numbers, dates of birth, and Social Security numbers, where required, should reference Appendix 11: (i.e., "See Appendix 11"). Financial account numbers should be listed by the last four digits of the financial account when the account is reported on a pleading or document filed with the Court. This form is neither approved nor disapproved by any court or judicial tribunal. Use of this form provides no immunity from error. Page 1 of 1 Personal and Financial Information for Guardianships and Conservatorships Ch6Art14App11 Rev 03/17 CC 16:2.23 Appendix 11 (Neb. Ct. R. ­ Chapter 6, Article 14) Adopted August 28, 2013; amended January 22, 2015; amended March 14, 2017. American LegalNet, Inc. www.FormsWorkFlow.com