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: ) ) ) CASE NO. Protected Person's Telephone #: ) ) FINAL CONSERVATORSHIP REPORT Instructions To Conservator Please type or print clearly using black ink. In preparing the report, you must consult with the protected person as much as possible (if the protected person is still living). 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 tell the court why your service as conservator is ending and what has happened to the protected person and the protected person's assets since you filed your last annual report. Reporting Period This report covers the period: From the end of the last reporting period: To the date my services as conservator ended: Information About Conservator Conservator's Name Mailing Address (box or street number) Check here if this mailing address is new. Relationship to protected person: Was a separate guardian appointed for the person? Page 1 of 11 PG-230 (2/05)(cs) FINAL CONSERVATORSHIP REPORT Daytime Phone (city) (state) (ZIP) No Yes Name: Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100 American LegalNet, Inc. www.USCourtForms.com Reason For Ending Conservatorship My conservatorship of the protected person has ended because: The protected person died on (date) at (location) A copy of the death certificate is attached. I did did not have possession of the protected person's will. On , 20 , I delivered the protected person's will to the court for safekeeping, as required by AS 13.26.285(e), and informed the executor or a beneficiary named in the will that the will had been so delivered. Name of person notified: , has been appointed. (name) I resigned as conservator. A new conservator, I was removed by the court. The court has terminated the conservatorship because Other (Explain): If the protected person is deceased or if the conservatorship has been terminated because the protected person regained the ability to manage his/her property and affairs, you need not fill out paragraphs 1-6. Skip to paragraphs 7 - 16. Information About Protected Person 1. Housing. Where does the protected person live now (name of facility or place)? Who takes care of the protected person? Type of Residence: nursing home 2. Medical Care. a. Describe in general terms the nature of the protected person's medical expenses during the reporting period (services received and cost). assisted living home b. Has there been a significant change in these expenses from the prior year? Yes No Explain: Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100 American LegalNet, Inc. www.USCourtForms.com Page 2 of 11 PG-230 (2/05)(cs) FINAL CONSERVATORSHIP REPORT 3. School and Job Training. Since the last report to the court, did the protected person attend school or receive any type of job training? No Yes. Describe studies (include name and location of school): Cost: 4. Work. Was the protected person employed at any time during the period since the last report to the court? 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 period since your last report to the court: Type of Contact How Often in person by telephone by mail or e-mail through 3rd person: other: 6. Decision Making. Have there been any changes in the protected person's ability to make decisions on financial matters? 7. Significant Actions. Describe any significant actions you took as conservator for the protected person during the period since your last report was filed with the court (including any actions taken regarding the protected property and funds): Page 3 of 11 PG-230 (2/05)(cs) FINAL CONSERVATORSHIP REPORT Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100 American LegalNet, Inc. www.USCourtForms.com 8. Additional Information. List any additional information about the protected person that you wish to report to the court: 9. Protected Person's Income Since Last Annual Report. (List only the income of the protected person. Do not list your income.) Amount Received Since Last Income Source Annual Report 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 Income Received Since Last Annual Report: Page 4 of 11 PG-230 (2/05)(cs) FINAL CONSERVATORSHIP REPORT Probate Rules 17(f) & (h) AS 13.26.255, .285(e), .310 & 13.06.100 American LegalNet, Inc. www.USCourtForms.com 10. Protected Person's Expenses Since Last Annual Report. (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.) Amount Spent Since Last Expense Description Annual Report 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: Burial Expenses: Other (list all other payments made): Total Expenses Since the Last Annual Report: 11. Money Controlled By Protected Person. Since the last annual report was filed, did the protected person have sole control over any money? Yes No If yes, please explain: Is this money included in the income and expenses listed in #9 and #10? Explain: Yes