Commonwealth of Massachusetts The Trial Court Probate and Family Court Docket No. CONSERVATOR'S FINANCIAL PLAN In the Interests of: First Name Division Middle Name Last Name Protected Person Date of Appointment of Conservator I, (name of Conservator(s)), M.I. First Name move this Court to approve this initial Last Name amended Conservator's Financial Plan dated . Protected Person's Information: Middle Name First Name Current Address (including Name of Living Center or Nursing Facility): Last Name (Address) (Apt, Unit, No. etc.) (City/Town) (State) Primary Phone # (Zip) Age: Conservator's Information: Middle Name First Name Do you plan on receiving any fees for being the Conservator? Occupation: Yes Last Name No If Yes, indicate hourly rate: $ Your Relationship to Protected Person: (Address) (City/Town) (Apt, Unit, No. etc.) (State) (Zip) Primary Phone # Part I - Financial Plan 1. Provide a short narrative of the steps you will take to develop or restore the Protected Person's ability to manage his or her own property and finances. 2. Estimate the likely duration of the conservatorship, keeping in mind the steps to be taken to restore the Protected Person's ability to manage his or her own affairs. MPC 831 (5/30/11) page 1 of American LegalNet, Inc. www.FormsWorkFlow.com 5 3. Are the assets in the estate sufficient to provide for the present and future care of the Protected Person? Yes No If No, describe why and what steps should be taken. If you would like the Court to take action, you must file an appropriate pleading (i.e. motion, petition for license to sell real estate, petition for protective arrangement) with the Court. 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. A. Receipts/Income Indicate the amount of 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 (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 Projected Annual Amount Amount Wages Social Security Interest / Dividends Pensions / Retirement Plan Distributions Rental Income Gifts from Others Disability, Unemployment or Worker's Compensation Other Public Assistance (Please List) Other Receipts/Income (Please List) Total Receipts/Income Enter the total projected monthly and annual amounts in Part II (A). MPC 831 (5/30/11) page 2 of American LegalNet, Inc. www.FormsWorkFlow.com 5 B. 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 Projected Annual Monthly Amount Amount Conservator: Guardian: Name Guardian ad litem: Name Legal fees for Protected Person: Attorney Name Legal fees for Conservator: Attorney Name Legal fees for Guardian: Attorney Name Accountant/CPA: Name Case Manager: Name Geriatric Care Manager: Name Other: Name Other: Name Total Professional Fees Enter totals in Part I - Section C Disbursements/Expenses. MPC 831 (5/30/11) page 3 of American LegalNet, Inc. www.FormsWorkFlow.com 5 C. Disbursements/Expenses Indicate the disbursements/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 Projected Monthly Projected Annual Amount Amount Total Professional Fees Paid (from Part B) Distributions to Protected Person Income Taxes FICA and Medicare Taxes Rent Mortgage Health Care (including health insurance, prescriptions) Other Insurance 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 (Please List) Other Disbursements/Expenses (Please List) Total Disbursements/Expenses Enter the total projected monthly and annual amounts in Part II (B). MPC 831 (5/30/11) page 4 of American LegalNet, Inc. www.FormsWorkFlow.com 5 Part II - Summary of Financial Plan (Receipts/Income Minus Disbursements/Expenses) Summarize the Financial Plan below after completing the detailed accounting information. Projected Monthly Amount Projected Annual Amount (A) Receipts/Income (Total from Part I A (above) $ $ (B) Disbursements/Expenses (Total from Part I C (above)) $ $ Net Income: (A) minus (B) $ $ The Conservator states the following: 1. The information contained in the 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 Financial Plan to the Protected Person in hand or by certified mail 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. I understand that I am required to maintain supporting documentation for all receipts and disbursements including detailed billing statements from any professional. The Court and/or Interested Persons may request copies at any time. I state under penalty of perjury that this is a true and complete Financial Plan of this estate to the best of my knowledge, information and belief. Date: Signature of Conservator Attorney or Conservator Without Attorney (Apt, Unit, No. etc.) (Address) (City/Town) (State) (Zip) Primary Phone #: BBO No.: CERTIFICATE OF SERVICE I certify that on I sent a copy of this Conservator's Financial Plan to the (date) Protected Person in hand or by certified mail , return receipt requested, at the address listed on page 1 of this Report. Signature of Person Making Service Print Name (Apt, Unit, No. etc.) (Address) (City/Town) (State) (Zip) Primary Phone #: BBO No.: Note:831 (5/30/11) Plan must be served on the Protected Person. MPC The Financial page 5 of American LegalNet, Inc. www.FormsWorkFlow.com 5