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 IMPLEMENTATION REPORT AND INVENTORY 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. 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: Has a separate guardian been appointed for the person? No Yes Name: Probate Rule 17(e) AS 13.26.250 & 13.06.100 American LegalNet, Inc. www.USCourtForms.com Daytime Phone (city) Yes No (state) Page 1 of 9 PG-220 (2/05)(cs) CONSERVATOR'S IMPLEMENTATION REPORT & INVENTORY 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. Information About Protected Person 1. Housing. Describe where the protected person lives: Name of facility or place: Address: (street address) (city) (state) Type of Residence: nursing home assisted living home If the protected person lives in your home, do you charge him/her rent? Yes If you live in the protected person's home, are you paying him/her rent? Yes 2. School and Job Training. Does the protected person attend school or any type of job training? Cost: 3. Work. Is the protected person employed? No. Yes. Describe (include type of work, name of employer, address, phone, and how long employed): 4. Contacts. Describe your contacts with the protected person since you were appointed conservator: Type of Contact How Often in person by telephone by mail or e-mail through 3rd person: other: 5. Decision Making. When a decision has to be made about the protected person's financial affairs, how are the decisions made? a. Describe decisions made by protected person alone: (ZIP) No No Page 2 of 9 PG-220 (2/05)(cs) CONSERVATOR'S IMPLEMENTATION REPORT & INVENTORY Probate Rule 17(e) AS 13.26.250 & 13.06.100 American LegalNet, Inc. www.USCourtForms.com b. Describe decisions made by conservator alone: c. Describe decisions made by conservator and protected person together: 6. Dependents. (List anyone the protected person is legally required to support.) Name Relationship to Person Date of Birth (if under 18) 7. Conservator Services. a. Briefly describe the conservator services you plan to provide to the protected person: b. What are you doing or planning to do to help the protected person learn to manage and protect his/her money? 8. Protected Person's Current Monthly Income. (List only the income of the protected person. Do not list any of your own income. Divide any yearly amounts by 12. Divide quarterly amounts by 3.) Income Source Social Security Benefits: a. SSA b. SSI Adult Public Assistance: Veterans Financial Benefits: Alaska Longevity Bonus: Permanent Fund Dividend: Native Corporation Dividend: Monthly Amount Page 3 of 9 PG-220 (2/05)(cs) CONSERVATOR'S IMPLEMENTATION REPORT & INVENTORY Probate Rule 17(e) AS 13.26.250 & 13.06.100 American LegalNet, Inc. www.USCourtForms.com Wages: Dividends/Interest: Rental Income: Pension: Annuities: Other: (describe) Total Monthly Income: 9. Protected Person's Monthly Expenses. (Money paid to anyone on behalf of the protected person or the protected person's legal dependents. Divide yearly amounts by 12. Attach extra pages if necessary.) Monthly Expense Description Amount 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 Monthly Expenses: Page 4 of 9 PG-220 (2/05)(cs) CONSERVATOR'S IMPLEMENTATION REPORT & INVENTORY Probate Rule 17(e) AS 13.26.250 & 13.06.100 American LegalNet, Inc. www.USCourtForms.com 10. . (date) (List all assets the person owns individually or jointly. Attach extra pages if necessary.) a. b. Cash on hand (not in an account) $ Burial Account Name of Bank or Institution Type of Account Account Number Balance (amount) (where located) Protected Person's Assets on c. Alaska Native Corporation Dividend Account Name of Bank or Institution Type of Account Account Number Balance d. List all other bank accounts, certificates of deposit, etc. Attach the most recent bank statement. Attach additional pages if necessary. Name of Bank or Institution Name(s) on Account Account Number Balance e. List all Brokerage Accounts, Stocks, Bonds, and Other Securities. Attach the most recent account statement. Attach additional pages if necessary. Name of Company Name(s) on Account Account Value on (date) Page 5 of 9 PG-220 (2/05)(cs) CONSERVATOR'S IMPLEMENTATION REPORT & INVENTORY Probate Rule 17(e) AS 13.26.250 & 13.06.100 American LegalNet, Inc. www.USCourtForms.com f. Retirement Accounts. Name of Company Beneficiary Current Value g. Life Insurance Policies (policies the protected person owns). Name of Company Beneficiary of Life Insurance Face Value of Life Insurance Cash Value of Life