GEORGIA PROBATE COURT STANDARD FORM Adult Conservatorship Inventory and Asset Management Plan INSTRUCTIONS I. Specific Instructions 1. II. This form is to be used pursuant to O.C.G.A. §29-5-30. General Instructions General instructions applicable to all Georgia probate court standard forms are available in each probate court. Effective 7/07 GPCSF 58 Complete American LegalNet, Inc. www.FormsWorkFlow.com GEORGIA PROBATE COURT STANDARD FORM PROBATE COURT OF COUNTY STATE OF GEORGIA ADULT CONSERVATORSHIP INVENTORY AND ASSET MANAGEMENT PLAN WARD: ESTATE NO. CONSERVATOR(S): REAL PROPERTY (Indicate if property is jointly owned and with whom) Description County Parcel 1 State Approximate equity $ Parcel 2 $ Parcel 3 $ INCOME FROM ALL SOURCES Social Security per year Yearly Total $ SSI (Supplemental Security Income) per year $ Retirement benefits per year (payor): $ Retirement benefits per year (payor): $ VA benefits per year $ Other income per year, including, e.g., alimony, annuity, or trust distributions (payor): $ Interest, dividend, or investment income $ YEARLY TOTAL OF ALL INCOME $ If the Ward is a beneficiary of a Trust, please show the name of the Trust, the Trustee, his/her address, telephone number, and attach an outline showing when and how payments are required to be made under the Trust and the criteria for payment: Effective 7/07 -1- GPCSF 58 Complete American LegalNet, Inc. www.FormsWorkFlow.com PERSONAL AND INTANGIBLE PROPERTY (Indicate if property is jointly owned and with whom) Approximate Current Value 1. Checking/Savings/Money Market/Certificates of Deposit/Liquid Accounts: Bank/Financial Institution/Broker Acct. No. Joint Owner (if any) $ $ $ $ 2. Stocks/Bonds/Investments (including retirement and profit-sharing accounts): a. held by brokers: Brokerage Firm or Institution Acct. No. Joint Owner (if any) $ $ $ $ $ b. privately held: Company/Issuer No. of Shares Joint Owner (if any) $ $ 3. Automobiles: Year/Make/Model V.I.N. Joint owner (if any) $ $ 4. Other assets of significant value: Description Joint owner (if any) $ $ $ TOTAL VALUE OF PERSONAL AND INTANGIBLE PROPERTY Effective 7/07 -2- $ GPCSF 58 Complete American LegalNet, Inc. www.FormsWorkFlow.com DEBTS AND OTHER LIABILITIES The ward owes the following debts/liabilities: 1. Secured debts: Obligor/Payee Collateral Solely/Jointly Owed Approx. Current Balance $ $ 2. Unsecured debts: Obligor/Payee Acct. No. Solely/Jointly Owed Approx. Current Balance $ $ TOTAL DEBTS AND OTHER LIABILITIES OF WARD $ AVERAGE MONTHLY LIABILITIES AND EXPENSES Household: Care Facility/Rent/Mortgage payments: $ Property taxes/Insurance $ Utilities/Lawn Care/Pest Control $ Miscellaneous household, food $ Total credit account and other debt payments $ Other (specify) $ Automotive/Transportation Fuel and Repairs $ Tags and license fees, Insurance $ Bus/train/taxi fares $ Minors or Other Dependents of the Ward Child Care $ School Tuition/Supplies/Expenses/Lunches $ Clothing/Diapers /Grooming/Hygiene $ Medical/Dental/Prescription $ Entertainment/Activities $ Other Insurance Health/Life/Disability $ Other (specify) $ Effective 7/07 -3- GPCSF 58 Complete American LegalNet, Inc. www.FormsWorkFlow.com Ward’s Other Expenses Laundry/Clothing/grooming/hygiene $ Medical/Dental/Prescriptions/medications $ Entertainment/Vacations/Subscriptions/Dues $ Personal Caretakers/cleaning personnel $ Other (specify) $ Total Expenses $ Is the ward behind in any debt payments? (yes) (no) If yes, payee and amount: The following extraordinary purchases are anticipated next year: SUMMARY 1. Average Monthly Income $ 2. Average Monthly Expenses ASSET MANAGEMENT PLAN Please describe how you plan to manage the ward’s assets, including details regarding sale, refinancing, reallocation, investments, or other actions, if any: (initial:) a. Therefore, based upon the expenses shown above, the Conservator(s) hereby request(s) leave to disburse from the ward’s estate the sum of $ per month for the support, care, education, health, and welfare of the ward and those persons who are entitled to be supported by the Ward. b. Therefore, based on the income of the Ward as shown above, the Conservator(s) hereby request(s) leave to disburse the ward’s income as estimated above for the support of the ward and those persons who are entitled to be supported by the Ward. Therefore, based on known one-time expenses, the Conservator(s) hereby request(s) leave to disburse from the Ward’s estate $ one time in the reporting year for the following purpose: c. Effective 7/07 -4- GPCSF 58 Complete American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT I/We, , Conservator(s) of the above Ward, do swear that the foregoing Inventory and Asset Management Plan contains a just, true, and complete inventory and budget of all property belonging to said ward within my/our possession, control, or knowledge. This Inventory and Asset Management Plan has been provided to the Guardian of the ward, if any, by first class mail. Sworn to and subscribed before day of me this , 20 . Conservator NOTARY/CLERK OF PROBATE COURT Printed Name My Commission Expires ---------------------------------------------------------------------------------------------------------------------------------Sworn to and subscribed before me this day of , 20 . Co-Conservator, if any NOTARY/CLERK OF PROBATE COURT My Commission Expires Effective 7/07 Printed Name -5- GPCSF 58 Complete American LegalNet, Inc. www.FormsWorkFlow.com IN THE PROBATE COURT OF COUNTY STATE OF GEORGIA IN RE: , WARD , CONSERVATOR(S) ) ) ) ) ) ) ) ESTATE NO. ASSET MANAGEMENT PLAN ORDER The Conservator(s) having filed an Asset Management Plan for the above estate, it is hereby ORDERED that the Conservator(s) is/are authorized to disburse from the Ward’s estate: (initial applicable) a. the sum of $ per month for the support of the Ward and his/her dependents. b. the income generated from the corpus of the Ward’s estate for the benefit of the Ward and those persons who are entitled to be supported by the Ward. c. the sum of $ one time during the reporting period for the support of the Ward and those persons who are entitled to be supported by the Ward. IT IS FURTHER ORDERED that said Conservator(s) shall show in the annual return how such funds actually were spent. SO ORDERED this day of , 20 . Probate Judge Effective 7/07 GPCSF 58 Complete American LegalNet, Inc. www.FormsWorkFlow.com