District Court Denver Probate Court ___________________ County, Colorado Court Address: In the Interest 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 AND MOTION FOR APPROVAL 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 Initial Amended Conservator’s Inventory with Financial Plan. 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 interest of the Protected Person. 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 Person as identified in the Order Appointing Conservator may request copies at any time. 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 and will indicate having done so by completing the Certificate of Service at the end of this form. (§ 15-14-404(4), C.R.S.) This matter is routine and expected to be unopposed. I will set this matter on the Non-Appearance docket by filing JDF 712. OR I will set this matter for hearing on the appearance docket. Notice to Interested Persons. 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 may not review or adjudicate these or other matters unless specifically requested to do so by an interested person. JDF 882 R7-12 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN AND MOTION FOR APPROVAL © 2012 Colorado Judicial Department for use in the Courts of Colorado Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Protected Person’s Information: (Name) Current Address: (Include Name of Living Center or Nursing Home) City: State: Zip Code: Telephone Number: Age: Conservator’s Information: (Name) Do you expect to receive 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 expect to receive 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 R7-12 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN AND MOTION FOR APPROVAL © 2012 Colorado Judicial Department for use in the Courts of Colorado Page 2 of 8 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) must be completed. Cash on Hand, Bank, Checking, Savings, Certificate of Deposits, and 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) Type of Policy None Face Amount of Policy Cash Value $ $ Total Pension, Profit Sharing, Annuities and Retirement Funds None Type of Plan Account # (401(k), IRA, 457, PERA, Military, etc.) (last 4-digits only, if applicable) Current Account Value (Note: List monthly or annual distributions in Part V, below) $ Total JDF 882 R7-12 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN AND MOTION FOR APPROVAL © 2012 Colorado Judicial Department for use in the Courts of Colorado $ Page 3 of 8 American LegalNet, Inc. www.FormsWorkFlow.com Motor Vehicles and Recreation Vehicles (Including Motorcycles, ATV’s, Boats, etc.) Year Make and Model Estimated Value None 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 General Household and Other Personal Property (Total value except for items listed below.) Estimated Value Value = what you could sell it for in its current condition. $ 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 R7-12 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN AND MOTION FOR APPROVAL © 2012 Colorado Judicial Department for use in the Courts of Colorado Page 4 of 8 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 Creditor None Account Number Balance (last 4-digits only) $ Accrued expenses associated with this proceeding (Total from Part C.) 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 R7-12 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN AND MOTION FOR APPROVAL © 2012 Colorado Judicial Department for use in the Courts of Colorado Page 5 of 8 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 (from Part D) 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. JDF 882 R7-12 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN AND MOTION FOR APPROVAL © 2012 Colorado Judicial Department for use in the Courts of Colorado Page 6 of 8 American LegalNet, Inc. www.FormsWorkFlow.com C. Accrued Liabilities to Professionals The Conservator requests that the accrued expenses of this proceeding of $__________ (identified in Part IV – Inventory of Liabilities/Debts) and as detailed below be approved by the Court as a one-time lump sum payment or as payments spread out over ____ months as identified below in Part D: Type of Professional and Name of Individual Amount Billed or Paid $ Legal Fees for Petitioner Legal fees for Protected Person Filing fee Court Visitor fee Guardian ad litem fee Other Total Accrued Expenses – Enter totals in Part IV – Inventory of Liabilities/Debts. $ D. Projected Payments to Professionals Do you expect to pay any fees to professionals, including any fees you receive for being the Conservator? No Yes 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 litem Legal fees for Protected Person 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. $ JDF 882 R7-12 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN AND MOTION FOR APPROVAL © 2012 Colorado Judicial Department for use in the Courts of Colorado $ Page 7 of 8 American LegalNet, Inc. www.FormsWorkFlow.com E. Bond Bond has been set in the amount of $ ___________________. Surety has been posted. The setting of bond was deferred pending filing of this Conservator’s Inventory with Financial Plan. The Conservator now requests that bond be set in the amount of $___________________. (§15-14-415, C.R.S.) Bond has been waived by the Court. VERIFICATION I verify that the facts set forth in this document are true as far as I know or am informed. I understand that penalties for perjury follow deliberate falsification of the facts stated herein. § 15-10-310, C.R.S. I understand that this report is subject to audit and verification. ______________________________________ Conservator’s Signature Date ______________________________________ Co-Conservator’s Signature Date Certificate of Service I certify that on _____________________ (date) a copy of this Conservator’s Inventory with Financial Plan was served on each of the following: Name of Person to Whom You are Sending this Document (Interested Persons) Relationship to Protected Person Address Manner of Service* Protected Person *Insert hand delivery, first class U.S. Mail, certified U.S. Mail, E-filed, or Fax. _____________________________________________ Signature of Person Certifying Service Note: A copy of the Conservator’s Inventory with Financial Plan must be provided to 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 R7-12 CONSERVATOR’S INVENTORY WITH FINANCIAL PLAN AND MOTION FOR APPROVAL © 2012 Colorado Judicial Department for use in the Courts of Colorado Page 8 of 8 American LegalNet, Inc. www.FormsWorkFlow.com