IN THE IOWA DISTRICT COURT FOR ___________________ COUNTY IN THE MATTER OF THE CONSERVATORSHIP OF __________________________ Probate No. ________________ Annual Report NOTE: If additional space is needed, please add a separate page as an attachment. 1. This report is for the period from ________________________ to ________________________. (Use ending date of last accounting where applicable.) 2. Total cash on hand at close of the last accounting was $_______________. 3. Total sum of funds received during this report period was $_______________. (Attach as Exhibit "A" itemization showing date received, source of funds and amount.) 4. Total sum of disbursements made during this report period was $_______________. (Attach as Exhibit "B" itemization showing date, who was paid and amount paid for item or service.) 5. The balance of cash on hand at the close of this report period is $_______________. 6. The other assets of the ward at the close of this report are: (Attach listing of assets held and the value or remaining balances marked Exhibit "C". If assets remained the same as of the last report, a copy of the last listing may be used.) 7. Changes made in investment during this report period. (Attach as Exhibit "D" itemized list of changes when applicable.) 8. The total value of assets of the ward at the close of this report period is $_______________. 9. Amount of conservator's bond is $_______________. Surety is: _______________. 10. (Check one) The ward has no guardian The name of the ward's guardian is: _________________________________________ 11. (Answer Number 11 only if ward has no guardian.) a. The residence and physical location of the ward is: ________________________________________________________________________ b. The ward's general physical and mental condition is: Rule 7.11 ­ Form 4 American LegalNet, Inc. www.FormsWorkFlow.com 12. Other information relating to affairs of the conservatorship: (If conservatorship has special circumstances which do not adapt to this form, add Exhibit "F" setting out special circumstances in detail.) 13. Fees for conservator are (Attach Affidavit per Iowa Code section 633.202.) 14. Fees for conservator's attorney (check one): Should be set by the court No fees requested Waived or not applicable (Attach Affidavit per Iowa Code section 633.202, if fees are requested.) I certify under penalty of perjury and pursuant to the laws of the State of Iowa that the preceding is true and correct. Date: ________________________ Signature of Conservator: [Name] /s/ ____________________________________________________ [Law firm] _____________________________________________________ [Mailing Address] _______________________________________________ [Telephone Number] ____________________________________________ [E-mail Address] ________________________________________________ [Additional E-mail Address] _______________________________________ (NOTE: Bank statements, checks, receipts, stubs and other items evidencing receipt of funds and payment must be available to the court on demand.) Rule 7.11 ­ Form 4 American LegalNet, Inc. www.FormsWorkFlow.com