Financial Report Conservator/Guardian PC-442 REV. 2/16 R E C E IV E D : CONNECTI CUT PROBATE COURTS R E C OR D ED : Instructions: 1) A fiduciary may use this financial report instead of filing an account for a conservatorship or guardianship of an estate of a minor or other estate not specified by the Probate Court Rules of Procedure unless the court has ordered the fiduciary to file an account. 2) Type or print the form in ink. 3) Attach supporting schedules if necessary to provide additional details or explanatory notes. 4) The fiduciary shall send a copy of this financial report to each party and attorney. 5) For additional information, see the Probate Court Rules of Procedure, sections 37.3 and 37.4. 6) Note to guardians of the estates of minors: Use of funds for support expenses for a minor requires prior court approval. Probate Court Name Estate of District Number Fiduciary (List name, address, and telephone number of each fiduciary.) EACH FIDUCIARY WHO SIGNS THIS FINANCIAL REPORT REPRESENTS UNDER PENALTY OF FALSE STATEMENT THAT: 1) This financial report is being filed for the following type of estate: conservatorship guardianship of an estate of a minor other (Specify): 2) The financial report is being filed for the following reason: Periodic financial report. C.G.S. section 45a-177 Final financial report 3) All taxes, expenses of administration and claims against the estate are shown below and have been paid. This financial report covers the period (Month, Day, Year): From To 4) The fiduciary has retained all supporting records for this financial report as required by the Probate Court Rules of Procedure, section 36.13, and the records are available for review upon request. 5) The following is a true and complete summary of the assets of the estate and the fiduciary's receipts, payments and distributions. Financial Report Conservator/Guardian American LegalNet, Inc. www.FormsWorkFlow.com PC-442 PAGE 1/4 Financial Report Conservator/Guardian PC-442 REV. 2/16 CONNECTI CUT PROBATE COURTS R E C O R DE D : Assets and Income Received Total amount reported on the inventory or on hand at the end of the accounting period in most recent financial report or account Total amount of additional assets received Income received: Interest Dividends Pension Social Security Annuities Wages Rent Other (Specify and attach second sheet if necessary.) Net amount of gain (or loss) on the sale of assets If real property has been sold, attach copy of settlement statement from closing. Total $ $ $ $ $ $ $ $ $ $ $ $ Payments Administration Expenses: Fiduciary fees Fiduciary disbursements Attorney's fees Attorney's disbursements Accounting expenses Probate court fees and expenses Probate bond premium Publication of notices Other expenses (Specify and attach second sheet if necessary.) Taxes: Town of Property Tax State of Connecticut Income Tax Internal Revenue Service Income Tax Other (Specify and attach second sheet if necessary.) Total $ $ $ $ $ $ $ $ $ $ $ $ $ $ Financial Report Conservator/Guardian American LegalNet, Inc. www.FormsWorkFlow.com PC-442 PAGE 2/4 Financial Report Conservator/Guardian PC-442 REV. 2/16 CONNECTI CUT PROBATE COURTS R E C O R DE D : Distributions to or for the Benefit of Person Under Conservatorship or Guardianship Enter the total amount of distributions made during the accounting period to or for the benefit of the person under conservatorship or guardianship in each of the following categories. Attach second sheet if necessary. Note to guardians of the estates of minors: Use of funds for support expenses for a minor requires prior court approval. Total Amount of Distributions Made to Medical Housing Utilities Automobile Spending Money Groceries Clothing Tuition Other expenses (Specify and attach second sheet if necessary.) During Accounting Period $ $ $ $ $ $ $ $ $ $ Total Amount on Hand at the End of the Accounting Period Enter the total amount on hand at the end of the accounting period at fair market value, except that assets that are difficult to value may be reported at the fiduciary acquisition value. If this is a final financial report for the estate, a proposed distribution must be submitted. See Form PC-442A. Total Assets On Hand $ EACH FIDUCIARY REQUESTS: (1) approval of this financial report; (2) approval of any proposed distribution, if applicable; and (3) release from liability with respect to all items shown in this financial report. The representations contained in this financial report are made under the penalty of false statement. Signature of Fiduciary Type or Print Name Date Signature of Fiduciary Type or Print Name Date Financial Report Conservator/Guardian American LegalNet, Inc. www.FormsWorkFlow.com PC-442 PAGE 3/4 Financial Report Conservator/Guardian PC-442 REV. 2/16 CONNECTI CUT PROBATE COURTS R E C O R DE D : Certification I certify that a copy of this financial report, including the Schedule of Proposed Distribution, if applicable, was sent to each of the following persons: Name and Address Signature of fiduciary or attorney _________________________________________________________________ Type or Print Name: ______________________________________________________________________________________________________ Date: ______________________________________________________________________________________________________________________ Financial Report Conservator/Guardian American LegalNet, Inc. www.FormsWorkFlow.com PC-442 PAGE 4/4