J DF 885 SC R 6 /1 9 Page 1 of 12 District Court Denver Probate Court County, Colorado Court Address: I n the Interest of : Protected Person COURT USE ONLY Attorney or Party Without Attorney (Name and Address): Phone Number: E - mail: FAX Number : Atty. Reg. #: Case Number: Division Courtroom REPORT ADULT MINOR ANNUAL REPORT AMENDED REPORT CURRENT REPORTING PERIOD FROM TO (MM/DD/YYYY) (MM/DD/YYYY) INTERIM REPORT DUE ON FINAL REPORT If Final Report, indicate why: Protected Person deceased Minor turned 21 Judicial Order PART A: CONTACT INFORMATION Check if Updated Information from last Report Name: Age : Street Address: (Include Name of Living Center or Nursing Home) City: State: Zip Code: Mailing Address, if different: Primary Phone : Alternate Phone : C Check if U pdated Information from last Report Name: Age : Occupation: Your Relationship to Protected Person: Street Address: City: State: Zip Code: Mailing Address, if different: City: State: Zip Code: Primary Phone : Alternate Phone: Email Address: Have you had any criminal charges filed against you or convictions entered since the last report? Yes No If Yes, explain: Co - (if applicable) Check if Updated Information from last Report American LegalNet, Inc. www.FormsWorkFlow.com J DF 885 SC R 6 /1 9 Page 2 of 12 Name: Age : Occupation: Your Relationship to Protected Person: Street Address: City: State: Zip Code: Mailing Address, if different: City: State: Zip Code: Primary Phone : Alternate Phone: Email Address: Have you had any criminal charges filed against you or convictions entered since the last report? Yes No If Yes, explain: *** Notice to Interested Person s : Interested persons have the responsibility to protect their own rights and interests within the time and in the manner provided by the Probate Code, including the appropriateness of disbursements, the compensation of fiduciaries, attorneys, and others, and the distribution of estate assets. Interested persons may file an objection with the c ourt. The c ourt will not review or adjudicate these or other matters unless specifically requested to do so by an interested person. P ART B : CONSERVATORSHIP ISSUES 1. Is there a continued need for the c onservatorship? Yes No If No , describe why and what steps should be taken. If you would like the c ourt to take action, you must file a motion with the c ourt. 2. Are the remaining assets in the estate sufficient to provide for the present and future care of the protected person? Yes No If No , describe why and what steps sh ould be taken. If you would like the c ourt to take action, you must file a motion with the c ourt. 3. Should there be a change in scope of the c onservatorship? Yes No If Yes , describe why and what steps should be taken. If you would like the c ourt to take action, you must file a motion with the c ourt. 4. Attach a copy of the b ond to this r eport, unless the b ond was waived or not required by the c ourt . What is the amount of the b ond? $ . Is the amount of the b ond sufficient to cover all unrestricted assets? Yes No If No , describe why and what steps should be taken. If you are requesting a change to the b ond, you must file a motion with the c ourt. INSTRUCTIONS ON HOW TO COMP LETE THIS FORM must be filed annually pursuant to 24715 - 14 - 420, C.R.S. Part C of this report concerns the information necessary to satisfy the court that the c onservator has maintained a complete accountin g of all financial transactions and managed the p rotected p Step 1 is a financial transaction detail and should be completed for each bank or investment account. A spreadsheet or report from personal accounting software may also be submitted in lieu of completing the transaction detail. American LegalNet, Inc. www.FormsWorkFlow.com J DF 885 SC R 6 /1 9 Page 3 of 12 Steps 2 and 3 summarize the income a nd expense for the reporting period and compare those amounts to the previous period or the Financial Plan. Explain the cause for any changes between the current period amounts and amount s from the prior period or the F inancial P lan. Step 4 reports a dditional detail for fees paid to professionals including the hourly rate, number of hour worked, and description of services provided. Steps 5 and 6 summarize assets and liabilities as of the reporting date and compare those amounts to the previous peri od or the Inventory. In addition to explaining the cause for any changes between the current period amounts and amounts from the prior period or the I nv entory, provide specific detail regarding any asset purchases or sales. Step 7 is a summary. T ransfer the respective income and expense totals from Steps 2 and 3 as well as the asset and liability totals in steps 5 and 6 to the appropriate lines in Step 7 to calculate the net income and net worth. Part C: FINANCIAL INFORMATION Step 1: Detail Listing of Receipts/Income and Disbursements/Expenses Complete this Detail f or all bank account s . Make additional copies of this form as necessary. Alternatively, Check Regist er form JDF 871, a spreadsheet, or a report from personal accounting software m ay be attached . Please l ist all transactions , includ ing Income (deposits) and Expenses ( withdrawals) , for the entire reporting period. Each Receipt/Income item should be listed in the Amount Received column and each Disbursement/Expense item should be listed in the Amount Disbursed column. ** Note: This report should resemble a check register for each bank account. Name of Bank: Account Number (last 4 - digits only): Date Check or I.D. No. Description of item Received or Disbursed, include Name of Payee (if Disbursement) Amount Received Amount Disbursed Page of May continue entries on Check Register Form JDF 871 $ $ American LegalNet, Inc. www.FormsWorkFlow.com J DF 885 SC R 6 /1 9 Page 4 of 12 Check here if additional detailed spreadsheets are attached to this report . Individual Bank Account Summary Beginning Cash Balanc e $ ( B alance from prior year Report or Inventory) Add: Total Amount of Income + $ ( T otal Income received from detail above ) Add: Total Amount Received as Transfer + $ (T otal transferred from other bank accounts) Less: Total Amount Disbursed - $ ( Total disbursements from detail above ) Less: Total Amount Transferred out - $ ( T otal transfers moved to other accounts) Ending Cash Balance = $ (Transfer this account balance to Step 5.) Step 2: Receipts and Income Column A : Is this the first a nnual Yes No If Yes , use the amounts from the Inventory with Financial Plan (JDF 882) to complete Col umn A that is marked with an asterisk (*) below. If No Column A that is marked with an asterisk (*) below. Column B : Transfer all individual income category totals from completed Detail Listing in Step 1 or attached spread sheet. Column C: Calculate and record the difference between Column A and Column B. Description of Receipt/Income Category List Total Receipts/Income from Detail Listing ( From Step 1 or Separate Spreadsheet) Column A * Total Amount of Receipts / Income from Prior Reporting Period or Financial Plan Column B Total Amount of Receipts / Income for Current Reporting Period Column C Change in Amount of Receipt/ Income Indicate +/ - Asset Not Previously Reported Business Income Court Order Repayment Disability / Unemployment / Distribution - Annuity Distribution Pension s /Retirement Plan Distribution Trust Farm/Ranch Income Gifts from Others Inheritance Insurance Settlement/Benefit Interest/Dividends Loan Repayment Oil/Gas /Mineral Royalties Other Public Assistance Other Receipts/Income Proceeds from Sale of Assets American LegalNet, Inc. www.FormsWorkFlow.com J DF 885 SC R 6 /1 9 Page 5 of 12 Rental Income Reverse Mortgage Payment Social Security Tax Refunds VA Benefits Wages TOTALS (Move to Step 7) Have Total Receipts/Income in Column B changed from the Prior Reporting Period or Financial Plan totals in Column A ? Yes No If Yes, explain the changes below. Please include a description of any changes or unanticipated transactions. If income and expenses are anticipated to differ going forward, it may be necessary to file an Amended Inventory with Financial Plan and Motion for Approval ( JDF 882) or