7013 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO.(Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF SOLANO STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: 600 Union Avenue P.O. Caller 5000 Fairfield, CA 94533 321 Tuolumne Street 321 Tuolumne Street Vallejo, CA 94590 IN RE THE GUARDIANSHIP OF: CASE NUMBER: CONFIDENTIAL PRELIMINARY INVENTORY OF PROBATE GUARDIANSHIP ESTATE INSTRUCTIONS Please provide as much information as you can about the proposed ward's assets. Complete a separate form for each child. I, , declare as follows: 1. A petition is currently pending for appointment of a guardian of the estate for the minor child named below: Name: Date of birth: 2. Is the child receiving any assets because he or she is named in a person's will or because he or she is an heir by intestate succession? No Yes (please provide the information indicated below) Name of court handling estate: Court's address: Case number: 3. LIFE INSURANCE a. Is the child a named beneficiary of any life insurance policies? b. If yes, how many life insurance policies? Name of insurance company: Address: Name of insured: Relationship of ward to insured: Amount of anticipated benefit payable to ward: Was this policy through the insured's employer? If yes, what is the name of the insured's employer? Information on additional policies is attached to this form. (Please be sure to include the case name and case number at the top of each page.) CONFIDENTIAL PRELIMINARY INVENTORY OF GUARDIANSHIP ESTATE Adopted for Mandatory Use Solano County Local Form no. 7013 Rev. 01/2012 American LegalNet, Inc. www.FormsWorkFlow.com No Yes I don't know 1 2 3 4 or more c. Please provide the following information about each life insurance policy: Yes No I don't know SCLR 15.2 Page 1 of 6 7013 IN RE GUARDIANSHIP OF: CASE NUMBER: 4. PENSIONS, ANNUITIES AND OTHER EMPLOYMENT-RELATED OR RETIREMENT PLAN BENEFITS a. Is the child a named beneficiary of any pension, annuity, retirement or other employment-related plans? Yes No I don't know 1 2 3 4 or more Rollover IRA Traditional IRA 457 b. If yes, how many? 401(k) c. Please identify the types of plans of which the child is a named beneficiary (check all that apply): SEP IRA Roth IRA California State Teachers Retirement System (CalSTRS) California Public Employees Retirement System (CalPERS) Federal Civil Service Retirement System (CSRS) Federal Employee Retirement System (FERS) Military Other public employer pension Private employer pension d. Please provide the following information about each plan or annuity of which the child is a named beneficiary: Name of plan: Address: Name of employee: Relationship of ward to employee: Amount of anticipated benefit payable to ward: Was this policy through the insured's employer? If yes, what is the name of the insured's employer? Information on additional plans is attached to this form. (Please be sure to include the case name and case number at the top of each page.) 5. SOCIAL SECURITY MINOR CHILD SURVIVOR'S BENEFITS Note: Minor child survivor's benefits are benefits payable by Social Security on a minor child's behalf due to the death of a parent. These benefits are considered the child's asset even if the benefits are payable to the surviving parent or to the guardian of the child's estate. In estimating the amount of the child's benefit, do not include any "widow/widower's" benefits payable to the deceased parent's surviving spouse. Yes No I don't know a. Is the child currently receiving any Social Security survivor's benefits? information indicated below) Monthly benefit amount: No Yes (please provide b. If the child is currently receiving benefits, are you the named representative payee? No Name: Address: CONFIDENTIAL PRELIMINARY INVENTORY OF GUARDIANSHIP ESTATE Adopted for Mandatory Use Solano County Local Form no. 7013 Rev. 01/2012 American LegalNet, Inc. www.FormsWorkFlow.com Yes Phone number: If you are not the named representative payee, who is? SCLR 15.2 Page 2 of 6 7013 IN RE GUARDIANSHIP OF: CASE NUMBER: c. Has the child received or will the child receive a lump sum benefit payment? Yes No I don't know If yes, what is the amount of the actual or anticipated lump sum payment? When was the payment received or when do you expect it? Has Social Security required you (or will they require you) to place this payment in a dedicated Yes (please provide the requested information below) No account? Name of financial institution: Type of account: Account number: d. If the child is not currently receiving Social Security survivor's benefits, have you applied for these No Yes (please provide information indicated below) benefits on the child's behalf? Date of application: Social Security office location (address): e. If you have not applied for these survivor's benefits on the child's behalf, do you plan to apply? Yes No I don't know If yes, when do you plan to apply? 6. SOCIAL SECURITY SSI AND SSDI Note: A child may be eligible for SSI or SSDI benefits if the child is disabled and/or comes within Social Security's income guidelines. Contact the Social Security Administration for more information about whether the child is eligible for benefits. Within days Not sure a. Is the child currently receiving Social Security Supplemental Security Income (SSI) or Social Security Disability Income (SSDI) benefits? No Yes I don't know If yes, what type of benefits is the child receiving? What is the monthly benefit amount?: b. Has the child received or will the child receive a lump sum SSI or SSDI benefit payment? Yes No I don't know If yes, what is the amount of the actual or anticipated lump sum payment? When was the payment received or when do you expect it? Has Social Security required you (or will they require you) to place this payment in a dedicated Yes (please provide the requested information below) No account? Name of financial institution: Type of account: Account number: c. If the child is not currently receiving SSI or SSDI benefits, is the child eligible for these benefits? No Yes I don't know SSI SSDI Both CONFIDENTIAL PRELIMINARY INVENTORY OF GUARDIANSHIP ESTATE Adopted for Mandatory Use Solano County Local Form no. 7013 Rev. 01/2012 American LegalNet, Inc. www.FormsWorkFlow.com SCLR 15.2 Page 3 of 6 7013 IN RE GUARDIANSHIP OF: CASE NUMBER: d. If the child is or might be eligible for SSI or SSDI benefits, have you appli