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Declaration Form. This is a California form and can be use in Sacramento Local County.
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Tags: Declaration, 5, California Local County, Sacramento
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ATTORNEY’S NAME OR PETITIONER NAME IN PRO PER
ATTORNEY’S BAR NUMBER:
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STREET ADDRESS:
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CITY, STATE, ZIP CODE:
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TELEPHONE NUMBER:
FAX:
EMAIL:
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IN THE SUPERIOR COURT OF THE STATE OF CALIFORNIA
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IN AND FOR THE COUNTY OF SACRAMENTO
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No.
Conservatorship of the ( ) person and
( ) estate of:
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Dept. 129
In re:
_____________________, Conservatee
(state name)
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FINAL ACCOUNT AND REPORT OF
CONSERVATOR AND PETITION FOR
APPROVAL OF ACCOUNT AND REPORT,
( ) AND FOR APPROVAL OF
CONSERVATOR’S FEES
( ) AND ATTORNEY’S FEES
( ) AND FOR DISTRIBUTION OF ASSETS
ON HAND
( ) OTHER (State):
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Hearing Date:
Time:
Calendar No.:
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Petitioner, ___________________, respectfully represents:
(Name)
1. Appointment. On __________, Petitioner was appointed as
(Date)
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Conservator of the person/estate of ____________________. The Letters of
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Administration were issued on _________. At all times since the appointment,
(Date)
(Name)
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Petitioner has been acting as the Conservator.
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OPTIONAL
PR-E-LP-028 (1.1.07)
-1Final Account and Report of Conservator
LOCAL RULE 15.100
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2. The conservatorship is no longer necessary because (check applicable box) ( ) the
conservatee is deceased, having passed away on: __________; ( ) The assets of
(Date)
the estate have been exhausted and there are no longer any assets remaining which
would require a conservatorship; ( ) The conservatorship has been terminated by
the court; ( ) Other (state reason):
3. Period of Account. The account and report covers the period beginning
__________, and ending ___________.
(Date)
(Date)
4. Inventory and Appraisement. The Inventory and Appraisement was filed on:
__________, showing the value of the estate to be: $ __________.
(Date)
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Supplemental Inventory and Appraisements was filed on: __________, stating the
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value of assets to be: $ ___________.
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5. Account Petitioner is chargeable and is entitled to credits, respectively, as set forth
in attached “Exhibit A’, summary of account, and supporting schedules.
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5a. Financial Account Statements. Note: The conservator must attach an original
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account statement stating value for any asset held at close of this accounting
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period from the following type of financial institution: insurance company, broker or
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agent, investment company or bank, securities broker-dealer, investment
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advisor or financial planner, bank trust, savings and loan, industrial bank or
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credit union. Check the applicable box:
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( ) Petitioner has attached the required financial institution statements on Exhibit
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“2”.
( ) Petitioner has filed herewith a separate affidavit captioned “Confidential
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Financial Statement” with attached financial institution statements containing
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confidential information.
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LOCAL RULE 15.100
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6. Interest Bearing Accounts. If applicable, check the box: ( ) All the cash was
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invested and maintained in interest bearing accounts or in investments authorized by
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law or the governing instrument, except for an account of cash that was reasonably
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necessary for the orderly administration of the estate.
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7. Sales, Purchases, Change in form of assets. During the period of this report; sales,
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purchases or change in form of assets ( ) did ( ) did not occur. If in the
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affirmative, describe the transactions.
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8. Unusual Items in the Account. There ( ) were ( ) were not unusual items in the
accounting requiring explanation. If in the affirmative, describe the transactions.
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9. Income from Business or Trade. There ( ) was ( ) was not any income or loss
from a trade or business. If in the affirmative, describe.
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10. Liabilities of the Estate. There ( ) are ( ) are not any outstanding debts (includes
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tax due, notes payable, court judgments) at the end of the accounting period. If in
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the affirmative, describe the debts, date of creditor claim, amount owed, terms:
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11. Bond Report.
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Fair Market, Value of Assets (do not include real property) : $ ___________
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Annual Income or Receipts from all sources:
$ ___________
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Total Bondable Estate:
$ ___________
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Current Bond:
$ ___________
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Current Assets in Blocked Account: $ ___________
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Total:
$ ___________
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Petitioner requests:
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( ) Additional Bond:
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( ) Reduction in Bond: $ ______________
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( ) No change in amount of bond.
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( ) Additional assets be ordered blocked as follows (state amount, financial
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$ ______________
institution):
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PR-E-LP-028 (1.1.07)
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12. Family or Affiliate Relationship.
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There ( ) were ( ) were not any family or affiliate relationships between the
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fiduciary and any agent hired by the fiduciary during the accounting period. If in the
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affirmative, describe.
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13. Veteran’s Administration.
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The conservatee ( ) was ( ) was not entitled to receive Veteran’s Administration
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Benefits.
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14. State Hospital.
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The conservatee ( ) was ( ) was not a patient on leave of absence from a state
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hospital.
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15. Testate/Intestate.
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If conservatee is deceased, check applicable box: ( ) conservatee died with a
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( ) Will ( )Trust; ( ) conservatee died without a ( ) Will ( )Trust.
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16. MediCal Benefits.
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If conservatee is deceased, check applicable box: conservatee ( ) did ( ) did not
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receive Medi-Cal Benefits.
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PR-E-LP-028 (1.1.07)
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17. Person Entitled to Notice.
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A request for Special Notice ( ) has ( ) has not been filed. If in the affirmative list
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name and address of person (1) requesting Special Notice:
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Name
Address
Adult/Minor
Relationship
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List all persons entitled to notice of the hearing on the petition, state name, address, &
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relationship to decedent of all heirs at law, beneficiaries of a Will or trust, named
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executors of a Will, named trustees of a trust.
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Name
Address
Adult/Minor
Relationship
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18. Distribution of Property on Hand.
Petitioner proposes to distribute the property on hand to (check applicable box):
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( ) The personal representative, (_______________), of the deceased decedent’s
(Name)
estate.
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( ) The successors in interest as follows, because the deceased conservatee’s
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estate subject to probate administrator does not exceed $100,000.
(Name)
(Address)
(Identify item, amount, or percent)
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( ) Other (state proposed distribution & basis):
(Name)
(Address)
(Identify item, amount, or percent)
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PR-E-LP-028 (1.1.07)
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19. Conservator Fees and Costs.
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Petitioner requests fees as follows:
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( ) Fees are waived or ( ) Not requested at this time.
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( ) Fees are requested in the amount of $ ____________ Itemization of services
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set forth by date, time spent, & hourly rate are set forth in Exhibit “3”. (Note: Exhibit “3”
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must include a statement of facts which must (1) show the nature and difficulty of tasks
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performed; (2) show the results achieved; (3) show the benefit of the services to the
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estate; (4) specify the amount requested for each category of service performed; (5)
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state the hourly rate of each person who performed services and the hours spent by
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each of them; (6) describe the services rendered in sufficient detail to demonstrate the
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productivity of the time spent.
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Petitioner requests:
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( ) No Conservator Costs/Expenses
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( ) Conservator Costs/Expenses advanced in the sum of $ ____________ be
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reimbursed. Itemization by date, amount, and purpose is set forth in Exhibit “3”.
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OPTIONAL
PR-E-LP-028 (1.1.07)
-8Final Account and Report of Conservator
LOCAL RULE 15.100
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20. Attorney Fees and Costs. (Note: Attorney must attach a separate verification in
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support of fees being requested)
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Petitioner requests attorney fees be approved as follows:
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( ) Fees are waived or ( ) Not requested at this time.
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( ) Fees are requested in the amount of $ ___________. Itemization of services
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set forth by date, time spent, & hourly rate are set forth in Exhibit “4”. (Note: Exhibit “4”
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must include a statement of facts which must (1) show the nature and difficulty of tasks
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performed; (2) show the results achieved; (3) show the benefit of the services to the
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estate; (4) specify the amount requested for each category of service performed; (5)
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state the hourly rate of each person who performed services and the hours spent by
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each of them; (6) describe the services rendered in sufficient detail to demonstrate the
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productivity of the time spent.
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If the attorney fees requested include a paralegal acting under the direction and
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supervision of an attorney, then set forth in Exhibit 4 the following information:
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(1) Describe the qualifications of the paralegal (including education, certification,
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continuing education, and experience); (2) state the hours spent by the paralegal and
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the hourly rate requested for the paralegal’s services; (3) describe the services
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performed by the paralegal; (4) state why it was appropriate to use the paralegal’s
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services in the particular case; (5) demonstrate that the total amount requested for the
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extraordinary services of the attorney and the paralegal does not exceed the amount
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appropriate if the attorney had performed the services without the paralegal’s
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assistance.
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Petitioner requests:
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( ) No Attorney Costs/Expenses
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( ) Attorney Costs/Expenses advanced in the sum of $ ____________ be
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reimbursed. Itemization by date, amount, and purpose is set forth in Exhibit “4”.
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OPTIONAL
PR-E-LP-028 (1.1.07)
-9Final Account and Report of Conservator
LOCAL RULE 15.100
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21. Compensation Paid from Conservatorship Estate to the Conservator or Attorney
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for Conservator without prior court order (Check applicable box):
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( ) Conservator compensation ( ) was ( ) was not paid.
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( ) Attorney fees ( ) were ( ) were not paid.
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If compensation or fees were paid, state:
Date
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Amount
To Whom Paid
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22. Other (Add any additional information or actions by the conservator to be included
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in the report for which court approval is requested:
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PR-E-LP-028 (1.1.07)
-11Final Account and Report of Conservator
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WHEREFORE, petitioner requests that:
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1. The within account and report be settled, allowed, and approved;
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2. All acts and transactions as set forth in the account and report be approved;
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3. The conservatorship be terminated.
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4. Petitioner be authorized and directed to pay from the conservatorship estate to:
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( ) petitioner the sum of $ ________ as compensation for conservator services
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rendered;
( ) petitioner costs advanced in the sum of $____________ during the period of this
account;
( ) attorney ______________ the sum of $ ________ as compensation for
(Name)
legal services rendered;
( ) attorney ______________ costs advanced in the sum of $____________ during
(Name)
account.
5. After payment of all services ordered the above petitioner be authorized and directed
to distribute the assets on hand as set forth in paragraph 18 of the petitioner.
6. Other (include additional requests not included above):
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7. Petitioner be discharged as conservator upon application to the court after filing
receipts of distribution.
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8. For other orders as the court may deem proper.
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DATED:
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__________________________________________
Signature
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PR-E-LP-028 (1.1.07)
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VERIFICATION
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I, ___________________ declare:
(Petitioner Name)
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I am the petitioner herein. I have read the foregoing account, report, and petition and
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the accompanying exhibits and schedules and know the contents and the same is true of my
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own knowledge except as to those matters which are therein stated upon my information and
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belief, and, as to those matters, I believe it to be true.
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The account contains a full statement of all charges against me and of all credits to
which I am entitled on account of the estate during the period embraced in the account.
Each item of expenditure therein set forth was actually paid out at the time and place
and to the person as therein specifically state.
I declare under penalty of perjury under the laws of the State of California that the
foregoing is true and correct and that this verification was executed on ________, at
(Date)
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Sacramento, California.
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________________________
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(Signature)
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PR-E-LP-028 (1.1.07)
-13Final Account and Report of Conservator
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(NOTE: A separate Summary of Account with Schedules is required for the period
beginning on the date of death of the Conservatee and ending on the last day of the
accounting)
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EXHIBIT “1”
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SUMMARY OF ACCOUNT
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CHARGES:
Property on hand at beginning of account
(or Inventories)
$__________
Additional property received (or Supplemental
Inventories)
__________
Receipts (Schedule A)
__________
Gains on Sale or Other Disposition
(Schedule B)
__________
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Net Income from trade or business
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(Schedule C)
__________
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TOTAL CHARGES
*$__________
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________
CREDITS:_
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Disbursements (Schedule D)
$__________
Losses on Sale or Other Disposition
(Schedule E)
__________
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Net loss from trade or business
(Schedule F)
__________
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Distributions (Schedule G)
__________
Property on hand at close of account
(Schedule H)
__________
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TOTAL CREDITS:
*$__________
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*Total Charges should equal Total Credits
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SCHEDULE A
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RECEIPTS
4
5
DATE
PAYEE AND PURPOSE
AMOUNT
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7
Social Security
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12
Retirement Income
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14
15
16
17
18
Interest Income
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20
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Dividend Income
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TOTAL: __________________
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SCHEDULE A
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RECEIPTS
4
5
DATE
PAYEE AND PURPOSE
AMOUNT
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7
Rental Income
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9
10
11
12
Other Receipts
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
TOTAL: __________________
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SCHEDULE B
1
GAIN ON SALE OR OTHER DISPOSITION
2
3
Description of Property
Inventory
Gain on
Value
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Sales Price
Sale
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6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
TOTAL: __________________
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SCHEDULE D
1
DISBURSEMENTS
2
3
DATE
PAYEE AND PURPOSE
AMOUNT
4
5
Housing (Mortgage/Rent)
$
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7
8
9
10
In-Home/Resident Care
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12
13
14
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Medication & Medical Supplies
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18
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20
21
22
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25
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TOTAL: __________________
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SCHEDULE D
3
DISBURSEMENTS
4
5
DATE
PAYEE AND PURPOSE
AMOUNT
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7
Food
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9
10
11
12
Utilities
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14
15
16
17
18
Telephone
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21
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Credit Cards/Finance Co.
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25
26
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TOTAL: __________________
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SCHEDULE D
2
DISBURSEMENTS
3
4
5
DATE
PAYEE AND PURPOSE
AMOUNT
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7
Repairs & Maintenance
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9
10
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12
Insurance Premiums
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14
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16
17
18
Bank Fees
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20
21
22
23
Bond Premiums
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25
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TOTAL: __________________
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SCHEDULE D
2
DISBURSEMENTS
3
4
DATE
PAYEE AND PURPOSE
AMOUNT
5
6
Accounting & tax Service Fees
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8
9
10
11
Taxes
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13
14
15
16
Administration Expenses & Fees
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18
19
20
21
22
Miscellaneous Disbursements
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24
25
26
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TOTAL: __________________
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OPTIONAL
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SCHEDULE E
1
LOSS ON SALE OR OTHER DISPOSITION
2
3
Description of Property
Inventory
Gain on
Value
4
Sales Price
Sale
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
TOTAL: __________________
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OPTIONAL
PR-E-LP-028 (1.1.07)
-22Final Account and Report of Conservator
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SCHEDULE G
1
DISTRIBUTIONS
2
3
Date
Name
Address
Relationship
4
Item
Distributed
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6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
TOTAL: __________________
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OPTIONAL
PR-E-LP-028 (1.1.07)
-23Final Account and Report of Conservator
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SCHEDULE H
1
PROPERTY ON HAND
2
Current Fair
3
4
*Carry Value
1. Bank/Credit Union Accounts
Market Value
xxxxxxxx
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(such as checking, savings, money
xxxxxxxx
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markets, certificate of deposit) (state
xxxxxxxx
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name of financial institution, account
xxxxxxxx
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number, & amount of hand at end date
xxxxxxxx
of account period)
xxxxxxxx
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2. Real Property
( ) None
( ) Listed below (state common street address,
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legal description, how title is held, and interest held
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by the conservatee)
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*(value stated from last acct or if no acct from Inventory & Appraisal)
SCHEDULE H
2
PROPERTY ON HAND
3
*Carry Value
4
5
Current Fair
Market Value
3. Stocks & Bonds: (List name of stock or identify the bond,
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# of shares, and value at end date of
7
account)
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9
10
11
12
13
14
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4. Automobile (state year, make, and model)
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17
18
19
20
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5. Furniture & Personal Effects:
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24
25
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27
*(value stated from last acct or if no acct from Inventory & Appraisal)
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SCHEDULE H
1
PROPERTY ON HAND
2
Current Fair
*Carry Value
3
4
Market Value
Other:
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6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
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TOTAL:
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$__________
$__________
*(value stated from last acct or if no acct from Inventory & Appraisal)
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OPTIONAL
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-26Final Account and Report of Conservator
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