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. CONSERVATOR'S ANNUAL REPORT Instructions Please type or print clearly using black ink. In preparing the report, you must consult with the protected person as much as possible. 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 give the court as complete a picture as possible of the protected person's current financial situation and what has happened in the last 12 months. Reporting Period This report covers the following period: From Information About Conservator Conservator's Name Mailing Address (box or street number) (city) (state) (ZIP) Check here if this mailing address is new. If you change your address, please notify the court. Residence Address (street address) Do you live with the protected person? Relationship to protected person: Page 1 of 11 PG-225 (9/08)(cs) CONSERVATOR'S ANNUAL REPORT Probate Rule 17(e) AS 13.26.255, .380(b) & 13.06.100 American LegalNet, Inc. www.FormsWorkflow.com To Daytime Phone (city) Yes No (state) Has a separate guardian been appointed for the protected person? Guardian's name: No Yes If you are a private conservator charging fees, is there a court order authorizing payment of fees and establishing an hourly rate and maximum monthly amount as required by Probate Rule 17 and AS 08.26.110? Yes No I do not charge fees. If you are a private professional guardian or conservator, do you have professional liability insurance? Yes. (Attach copy of current Declarations page showing liability limits.) No. Changes in Conservatorship Needed · Is there a current need for change in the conservatorship? If yes, explain: No Yes If you want the court to change its order, please file form PG-190. · If this is a Public Guardian appointment, is a suitable private conservator available? No Yes Information About Protected Person 1. Housing. a. Describe where the protected person lives: Name of facility or place: Address: (street address) (city) (state) Type of Residence: nursing home assisted living home Has the protected person moved in the past year? If yes, explain: Yes No (ZIP) b. c. 2. If the person lives in your home, do you charge him/her rent? If you live in the person's home, are you paying him/her rent? Yes Yes No No Medical Care. a. Describe in general terms the nature of the protected person's medical expenses during the reporting period (services received and cost). b. Has there been a significant change in these expenses from the prior year? Yes No Explain: Probate Rule 17(e) AS 13.26.255, .380(b) & 13.06.100 American LegalNet, Inc. www.FormsWorkflow.com Page 2 of 11 PG-225 (9/08)(cs) CONSERVATOR'S ANNUAL REPORT 3. School and Job Training. Has the protected person attended school or any type of job training in the past 12 months? Cost: 4. Work. Has the protected person been employed at any time during the past 12 months? 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 past 12 months: How Often Type of Contact in person by telephone by mail or e-mail through 3rd person: other: 6. Decision Making. a. Have there been any changes in the protected person's ability to make decisions on financial matters? b. What have you done to help the protected person learn to manage and protect his/her money? c. When a decision has to be made about the protected person's financial affairs, how are the decisions made? (1) Describe decisions made by protected person alone: (2) Describe decisions made by conservator alone: (3) Describe decisions made by conservator and protected person together: Page 3 of 11 PG-225 (9/08)(cs) CONSERVATOR'S ANNUAL REPORT Probate Rule 17(e) AS 13.26.255, .380(b) & 13.06.100 American LegalNet, Inc. www.FormsWorkflow.com 7. Significant Actions. Describe any significant actions you have taken as conservator for the protected person during the past 12 months (including any actions taken regarding the protected person's property and funds): 8. Protected Person's Annual Income. (List only income of protected person during the 12-month reporting period, not your income.) Annual Amount Income Source 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 Annual Income: Total Annual Income During Previous Reporting Period: Change in Annual Income Since Previous Reporting Period Explain any difference more than $1000: Page 4 of 11 PG-225 (9/08)(cs) CONSERVATOR'S ANNUAL REPORT Probate Rule 17(e) AS 13.26.255, .380(b) & 13.06.100 American LegalNet, Inc. www.FormsWorkflow.com 10. Protected Person's Annual Expenses. (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.) Description Annual Amount 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: Other (list all other payments made): Total Annual Expenses: Total Annual Expenses During Previous Reporting Period: Change in Annual Expenses Since Previous Reporting Period Explain any difference more than $1000: 11.