‰District Court ‰Denver Probate Court __________________________________ County, Colorado Court Address: In the Interests of: COURT USE ONLY Protected Person Attorney or Party Without Attorney (Name and Address): Case Number: Phone Number: FAX Number: Division E-mail: Atty. Reg. #: Courtroom CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN DATE OF APPOINTMENT _____________ (MM/DD/YYYY) INVENTORY VALUES AS OF DATE _____________ (MM/DD/YYYY) FILING DUE DATE ________________ (MM/DD/YYYY) I ___________________________________ (name of Conservator), move this Court to approve this ‰Amended Conservator’s Inventory with Financial Plan filed on ______________________ (date). ‰Initial As grounds therefore, the Conservator states the following: 1. The information contained in the Inventory with Financial Plan is true and complete. The proposed plan is necessary to protect and manage the income and assets of the protected person. 2. The Financial Plan is based on the actual needs and best interests of the protected person. I understand that I must provide copies of this Inventory with Financial Plan to the protected person and any others as identified in the Order Appointing Conservator, within 10 days of filing with the Court pursuant to §1514-404(4), C.R.S. and will indicate having done so by completing the Certificate of Service at the end of this form. I understand that I am required to maintain supporting documentation for all receipts and disbursements including detailed billing statements from any professional. The Court or any Interested Persons as identified in the Order Appointing Conservator may request copies at any time. I understand that interested persons have the right to review and respond to information contained in the Inventory with Financial Plan within 30 days of the date of service or by the date of any hearing, whichever occurs first. Notice to Interested Person. 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 Court. The Court will not review or adjudicate these or other matters unless specifically requested to do so by an interested person. Protected Person’s Information: _________________________________________ (Name) Current Address: ____________________________________________________________________________ (Include Name of Living Center or Nursing Home) City: ______________________________ State: ______________________ Zip Code: _______________ Telephone Number: ______________________________________ Age: ________ JDF 882 3/08 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN Page 1 of 7 American LegalNet, Inc. www.FormsWorkflow.com Conservator’s Information: ________________________________________ (Name) Do you plan on receiving any fees for being the Conservator? ‰Yes ‰No If Yes, indicate hourly rate: $_______ Occupation: _______________________ Your Relationship to Protected Person: _______________________ Address: __________________________________________________________________ Apt. #__________ City: _______________________________ State: ______________________ Zip Code: ________________ Telephone Numbers: Home ___________________ Work ____________________ Cell ___________________ E-Mail Address: _____________________________________________________________________________ If applicable, Co-Conservator’s Information: ___________________________ (Name) Do you plan on receiving any fees for being the Conservator? ‰Yes ‰No If Yes, indicate hourly rate: $_______ Occupation: _______________________ Your Relationship to Protected Person: _______________________ Address: ___________________________________________________________________ Apt. #__________ City: ______________________________ State: ______________________ Zip Code: ________________ Telephone Numbers: Home ___________________ Work ____________________ Cell ___________________ E-Mail Address: _____________________________________________________________________________ Part I – Summary of Inventory Summarize the Inventory below after completing the detailed accounting information in Parts III and IV. (A) Total Assets (Total from Part III) $ _____________ (B) Total Liabilities/Debt (Total from Part IV) $ _____________ Net Worth: (A) minus (B) $ _____________ Part II – Summary of Financial Plan (Receipts/Income Minus Disbursements/Expenses) Summarize the Financial Plan below after completing the detailed accounting information in Part V. Projected Monthly Amount Projected Annual Amount (A) Receipts/Income (Total from Part V(A below)) $ _____________ $ _____________ (B) Disbursements/Expenses (Total from Part V(B) below) $ _____________ $ _____________ $ _____________ $ _____________ Net Income: (A) minus (B) JDF 882 3/08 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN Page 2 of 7 American LegalNet, Inc. www.FormsWorkflow.com Part III – Inventory of Assets Report the fair market value of each category of asset in the chart below as of the Inventory date. By indicating “None”, you are stating affirmatively that the protected person does not have assets in that category. Note: If additional space is needed, separate sheets may be used. If additional items are discovered after the initial inventory has been completed, a supplemental inventory listing those additional item(s) shall be completed. Cash on Hand, Bank, Checking, Savings, Certificate of Deposits, or Health Accounts (Name of Bank or Financial Institution) Type of Account ‰ None Account # (last 4digits only) Balance $ $ Total Stocks, Bonds, Mutual Funds, Securities and Investment Accounts ‰None Number of Shares or Identify Account Number Current Value (last 4-digits only) $ $ Total Life Insurance (Name of Company/Beneficiary) ‰ None Type of Policy Face Amount of Policy Cash Value $ $ Total Pension, Profit Sharing, Annuities or Retirement Funds ‰ None Type of Plan Account # (401(k), IRA, 457, PERA, Military, etc.) (last 4-digits only, if applicable) Current Value $ $ Total JDF 882 3/08 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN Page 3 of 7 American LegalNet, Inc. www.FormsWorkflow.com Motor Vehicles & Recreation Vehicles (Including Motorcycles, ATV’s, Boats, etc.) Year Make and Model ‰ None Estimated Value Value = what you could sell it for in its current condition. $ $ Total Real Estate (Indicate address) ‰ None Type of Property (Home, Rental, Land, etc.) Estimated Value Value = what you could sell it for in its current condition. $ $ Total General Household and Other Personal Property. ‰ None Estimated Value Value = what you could sell it for in its current condition. General Household and Other Personal Property (Total value except for items listed below.) $ Separately list and value items of significant value below, for example: Jewelry, Antiques, Collectibles, Artwork, etc. $ Total Miscellaneous Assets (List each one separately and be specific.) ‰ None Estimated Value Value = what you could sell it for in its current condition. $ Total $ Total Assets $ Enter this amount in Part I. JDF 882 3/08 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN Page 4 of 7 American LegalNet, Inc. www.FormsWorkflow.com Part IV – Inventory of Liabilities/Debts Report the value of each liability/debt in the chart below as of the Inventory date. Description of Liability/Debt Name of Financial Institution Account Number (last 4-digits only) Balance $ Mortgages (principal due only) Car Loans Home Improvement Loans Student Loans Credit Card Debt Federal Taxes Owed State and Local Taxes Owed Other Liabilities/Debt (Please list) Other Liabilities/Debt (Please list) $ Total Liabilities/Debt Enter this amount in Part I. Part V – Financial Plan List all expected sources of receipts/income and disbursements/expenses in the charts below. If a specific category is not applicable, indicate “0” in the projected monthly and annual amounts columns. You will use these amounts when you file the initial Conservator’s Report. A. Receipts/Income Indicate the amount of cash receipts/income received on both a monthly and annual basis. If an income amount (such as wages) is to be received on a monthly basis, multiply the amount by 12 to determine the projected annual amount. If an income amount (such as dividends) is to be received on an annual basis, divide the amount by 12 to determine the projected monthly amount. Description of Receipt/Income Category Projected Monthly Amount Projected Annual Amount Wages Social Security Interest / Dividends Pensions / Retirement Plan Distributions Rental Income Gifts from Others Disability, Unemployment or Worker’s Compensation Other Public Assistance Other Receipts / Income (Please list) Other Receipts / Income (Please list) Total Receipts/Income Enter the total projected monthly and annual amounts in Part II. JDF 882 3/08 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN Page 5 of 7 American LegalNet, Inc. www.FormsWorkflow.com B. Disbursements/Expenses Indicate the cash disbursement/expense amount on both a monthly and annual basis. If an expense (such as utilities) is to be paid on a monthly basis, multiply the amount by 12 to determine the projected annual amount. If an expense (such as property taxes) is to be paid on an annual basis, divide the amount by 12 to determine the projected monthly amount. Description of Disbursement/Expense Category Total Professional Fees Paid (from Part C) Projected Monthly Amount Projected Annual Amount $ $ $ $ Distributions to Protected Person Income Taxes FICA and Medicare Taxes Health Care (including health insurance, prescriptions) Other Insurance Rent or Mortgage Property Taxes and Assessments Repairs and Maintenance Utilities, including phones Home Furnishings Food and Household Supplies Clothing Personal Care Auto Expenses Education Entertainment, Vacations and Travel Monthly Debt Repayments (excluding mortgage) Other Disbursements/Expenses, e.g. gifts (Please list) Other Disbursements/Expenses (Please list) Total Disbursements/Expenses Enter the total projected monthly and annual amounts in Part II. C. Projected Payments to Professionals Do you expect to pay any fees to professionals, including any fees you receive for being the Conservator? ‰Yes ‰No If Yes, list below projected payments to professionals that will serve you, as conservator, the protected person or the estate. Include any fees you plan to receive as the Conservator. Type of Professional and Name of Individual Projected Monthly Amount Projected Annual Amount Conservator Guardian Guardian ad litemLegal fees for Protected Person - JDF 882 3/08 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN Page 6 of 7 American LegalNet, Inc. www.FormsWorkflow.com Legal fees for Conservator Legal fees for Guardian Legal fees for Petitioner Accountant / CPA Case Manager Other Other Total Professional Fees – Enter totals in Part V – Section B Disbursements/Expenses. $ $ I state under penalty of perjury that this is a true and complete Inventory with Financial Plan of this estate, during the period shown, both dates inclusive, to the best of my knowledge, information and belief. I understand that this report is subject to audit and verification. ______________________________________ ______________________________________ Conservator’s Signature Co-Conservator’s Signature Date Date Subscribed and affirmed, or sworn to before me in the County of ________________________, State of ____________________, this _______ day of ________________, 20 ____. Subscribed and affirmed, or sworn to before me in the County of _________________________, State of ___________________, this ________ day of ________________, 20 ____. My Commission Expires: __________________ My Commission Expires: __________________ _______________________________________ Notary Public/Clerk ______________________________________ Notary Public/Clerk Certificate of Service I certify that on _____________________ (date) the original was e-filed/filed with the Court and a copy of this Conservator’s Inventory with Financial Plan was served on each of the following: Name of Person You are Sending this Document To (Interested Persons) Relationship to Protected Person Address Manner of Service* *Insert hand delivery, first class U.S. Mail, certified U.S. Mail, E-filed, or Fax. _____________________________________________ Signature of Person Certifying Service Note: The Inventory with Financial Plan must be served on the protected person pursuant to §15-14-404(4), C.R.S. and interested persons pursuant to the Order Appointing Conservator, unless otherwise ordered. JDF 882 3/08 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN Page 7 of 7 American LegalNet, Inc. www.FormsWorkflow.com