State of Minnesota County of __________________ District Court ________________ Judicial District Probate / Mental Health Division Court File No. ___________________ Case Type: 14, Conservatorship In Re: Conservatorship of ______________________________, Protected Person _________ ANNUAL ACCOUNT or FINAL ACCOUNT For Period Ending: _______________ Date of Appointment: _______________ The annual account is summarized on these first two pages. Pursuant to General Rule of Practice for District Courts, Rule 11, restricted identifiers and financial source documents are confidential. See Forms 11.1 and 11.2. Do not list financial account numbers or social security numbers on this form. List such information on Form 11.1. Assets and Income 1. Beginning Balance: Total Class II property from Inventory for the first annual account, or the balance of personal property assets on hand per the last annual account 2. Other income 3. Social Security 4. Pension /VA Benefits 5. Interest income 6. Dividend income 7. Proceeds from sale of assets 8. Assets omitted from inventory 9. Refunds 10. Other increases Amount Deductions and Expenses Amount 1. Bond premiums 2. Attorney fees 3. Accrued attorney fees 4. Conservator fees 5. Accrued conservator fees 6. Taxes 7. Rent / Mortgage 8. Inventory value of asset sold 9. Other decreases Total Assets and Income Total Debts and Deductions Total Assets and Income Less: Total Debts and Deductions Total Personal Property Assets on Hand: (This should equal the total personal property assets on hand, below) ( ) GAC 14 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 10 American LegalNet, Inc. www.FormsWorkFlow.com Description of Assets on Hand Do not list financial account numbers here; list confidential information on Form 11.1 1. Bank Account (include verification form 15-UVF) 2. Stocks (include verification form 15-UVS) Value 3. 4. 5. 6. 7. Less: accrued attorney fees and accrued conservator fees Total Personal Property Assets on Hand (This total must match total personal property assets on hand, above) ( ) 1. 2. Tangible personal property ____ was / ____ was not, disposed of during the year. Real estate ____ was / ____ was not, disposed of during the year. (If real estate is sold during the year you must attach a closing statement to this account) The conservator represents that there is/are on file and in force the following bond(s) (list the name and address of each bonding company and the amount of each bond): ________________________________________________________________________ ________________________________________________________________________ The protected person's current address and phone number is: 3. 4. 5. OR I have never been removed for cause from serving as a conservator or guardian. I have been removed for cause from serving as a conservator or guardian and the court location and court file number are: 6. The following changes have occurred that affect the accuracy of information contained in the most recent criminal background study conducted under Minn. Stat. � 524.5-118: (Describe changes or write N/A if no changes have occurred) GAC 14 State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 10 American LegalNet, Inc. www.FormsWorkFlow.com 7. Pursuant to Minn. Stat. � 524.5-102, subd. 13a, a "professional guardian" or "professional conservator" means a person acting as guardian or conservator for three or more individuals not related by blood, adoption, or marriage. (check boxes below if applicable) I am a professional conservator according to the above definition. My answer to the above question reflects a change in my professional status since my last report to the court for this case. 8. I have received the following amount of reimbursement for services rendered to the protected person in the past year and this amount was not reimbursed by county contract: $ I can be contacted at: a. Telephone number: b. Address: 9. (List street/service address only; PO Boxes not acceptable) 10. CHOOSE ONE OF THE FOLLOWING: The conservator does not request a hearing to examine, settle, and allow this Account. The conservator requests a hearing to examine and, settle, and allow this Account. (Additional service requirements apply � page 4 must be completed) This is a Final Account and the conservator requests to be discharged from its duties and that the conservator's surety, if any, be discharged. (Additional service requirements apply � page 4 must be completed) Note: A hearing is required: *If this is a final account *If it has been five years since the last account was heard and allowed, See Minn. Gen. R. Prac. 416 (but note that Ramsey County and Hennepin County require a hearing after the first annual account and every third year thereafter; also note accounts of $20,000 or less may be waived by the court) The Annual Account must be completed by the conservator and filed with the court. If not filed within 60 days after the anniversary date of the appointment as conservator, the court shall issue an order to show cause. GAC 14 State ENG Rev 7/15 www.mncourts.gov/forms Page 3 of 10 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF MINNESOTA COUNTY OF ) ) SS ) I ______________________________, say that I have read this account, including the confidential portion therein, that this account is the true and full account of my administration of the estate and of all property belonging to the protected person which has come into my hands or to my knowledge, that I do not know of any error in the account, that I have read the petition and that it is true. I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. � 358.116. Dated:_____________, 20___ Signature of Conservator / Co-Conservator Name: Address: Telephone: E-mail address: I declare under penalty of perjury that everything I have stated in this document is true and correct. Minn. Stat. � 358.116. Dated: , 20 Signature of Co-Conservator Name: Address: Telephone: E-mail address: Name of Conservator's Attorney: Name: License No.: Address: Telephone: E-mail address: GAC 14 State ENG Rev 7/15 www.mncourts.gov/forms Page 4 of 10 American LegalNet, Inc. www.FormsWorkFlow.com AFFIDAVIT OF SERVICE State of Minnesota County of ) ) ) ______________________________________, states the following: that a copy of the Account and Notice of Rights to Petition for Restoration to Capacity and Other Relief has been given to the Protected Person and