Nebraska State Court Form REQUIRED APPLICATION FOR APPROVAL OF MONTHLY BUDGET OF GUARDIAN CC 16:2.41 Page 1 of 9 CC 16:2.41 Rev. Application for Approval of Monthly Budget of Guardian IN THE COUNTY COURT OF COUNTY, NEBRASKA IN THE MATTER OF Ward/Incapacitated Person Case APPLICATION FOR APPROVAL OF MONTHLY BUDGET , guardian for the ward/incapacitated person named above, requests that the court approve a monthly budget including any payments to be made to the guardian as shown below and that this budget remain in place from year to year until it is changed by the court. Monthly Income: Social Security (either retirement or disability) Supplemental Security income Support payment of any type (e.g. alimony, child support) Wages - name of employer is (Fill in name: ) Other (d escribe source) Other (d escribe source) Other (d escribe source) Total Income Monthly Expenses: Rent and utilities paid to guardian Board (food) paid to guardian Rent and utilities paid to someone else ( Fill in Name: ) Board (food) paid to someone else (Fill in Name: ) Transportation expense paid to guardian Transportation Expense paid t o someone else (Fill in Name: ) Spending money for the ward/incapacitated person Other (describe payment) Other (describe p ayment) Other (describe p ayment) Other (describe p ayment) Total Expenses American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 9 CC 16:2.41 Rev. Application for Approval of Monthly Budget of Guardian (Initial if being requested) I request that the court authorize cash withdrawals by the guardian from American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 9 CC 16:2.41 Rev. Application for Approval of Monthly Budget of Guardian UPDATED INVENTORY TO THE GUARDIAN: To protect personal information, only the last four digits of the account should be provided on this form. Complete account information is provided on the Personal and Financial Information for Guardianships and Conservatorships form. The inventory listed below is the inventory as of the ending date of this Annual Budget Report, . 1.PERSONAL PROPERTY: Checking Accounts Bank Name Account no.XXX- $ Bank Name Account no. XXX- $ Bank Name Account no. XXX- $ Savings Accounts Bank Name Account no.XXX- $ Bank Name Account no. XXX- $ Bank Name Account no. XXX- $ Certificates of Deposit Bank Name Account no.XXX- $ Bank Name Account no. XXX- $ Bank Name Account no. XXX- $ Stocks and Bonds$ Vehicles$ Household goods and furnishings$ Other: $ TOTAL: $ American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 9 CC 16:2.41 Rev. Application for Approval of Monthly Budget of Guardian 2.JOINTLY HELD PROPERTY: With whom $ What $ With whom $ What $ TOTAL: $ 3.INCOME (Monthly): Wages - Employer name: $ Social Security $ Supplemental Security income $ Veterans Administration benefits $ Company pension $ Interest - From where: $ Dividends - From where: $ Other: $ TOTAL: $ 4.CREDIT CARD(S) belonging to ward/incapacitated person (If applicable) Card Name Account no.XXX- $ Card Name Account no. XXX- $ TOTAL: $ American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 9 CC 16:2.41 Rev. Application for Approval of Monthly Budget of Guardian I swear or affirm, under the penalties of perjury, that I have examined the above documents, and to the best of my knowledge and belief, they are true, correct and complete. Date Signature(s) of Guardian(s) Print or Type Name of Guardian(s) Bar Number and Firm Name (attorneys only) Street Address/P.O. Box of Guardian(s) City/State/ZIP Code of Guardian(s) Phone of Guardian(s) E-mail Address of Guardian(s) American LegalNet, Inc. www.FormsWorkFlow.com Page 6 of 9 CC 16:2.41 Rev. Application for Approval of Monthly Budget of Guardian NOTICE OF RIGHT TO OBJECT WHEN A HEARING HAS BEEN SCHEDULED TO THE GUARDIAN: As uardian, you must complete and mail this form to all interested and file it with the court. You are notified that , guardian, has filed the following in the above referenced case on . Date document(s) filed Application for Approval of Monthly Budget and Inventory Other: If you object to the contents or accuracy of these filings, you may file an objection before the date of the scheduled hearing. The Objection form can be obtained on the Nebraska Supreme Court website, . Date Signature(s) of Guardian(s) Print or Type Name of Guardian(s) Bar Number and Firm Name (attorneys only) Street Address/P.O. Box of Guardian(s) City/State/ZIP Code of Guardian(s) Phone of Guardian(s) E-mail Address of Guardian(s) American LegalNet, Inc. www.FormsWorkFlow.com Page 7 of 9 CC 16:2.41 Rev. Application for Approval of Monthly Budget of Guardian CERTIFICATE OF MAILING TO THE GUARDIAN: You need to complete and file this form with the courtshowing that you I, , swear or affirm, under the penalties of perjury, that on ,I mailed copies of the forms marked below to all interested persons* and bonding company, if any, at the addresses set forth below: Application for Approval of Monthly Budget and Inventory;Notice of Hearing;Notice of Right to Object form; andCertificate of Mailing. NAME ADDRESS See attached (more names and addresses than above) Date Signature(s) of Guardian(s) Print or Type Name of Guardian(s) Bar Number and Firm Name (attorneys only) Street Address/P.O. Box of Guardian(s) City/State/ZIP Code of Guardian(s) Phone of Guardian(s) E-mail Address of Guardian(s) Ward/Incapacitated PersonCase American LegalNet, Inc. www.FormsWorkFlow.com Page 8 of 9 CC 16:2.41 Rev. Application for Approval of Monthly Budget of Guardian *Interested persons are defined as:children and spouses;future heirs if the ward/incapacitated person would die without leaving a valid will (brothers andsisters who are adults, grandparents, etc.);a trustee of any trust executed by the ward/incapacitated person;if after death of the ward/incapacitated person, interested person also includes the personalany governmental agency paying benefits on behalf of the ward/incapacitated person; andany person designated by order of the court to be an interested person. If there are no interested persons identified for a ward/incapacitated person, the court shall appoint a guardian ad litem (Nebraska Supreme Court Rule 247 6-1449(B)). The cost of the guardian ad litem may be taken from the assets of the ward/incapacitated person. American LegalNet, Inc. www.FormsWorkFlow.com Nebraska State Court Form REQUIRED PERSONAL AND FINANCIAL INFORMATION FOR GUARDIANSHIPS AND CONSERVATORSHIPS CC 16:2.23 Neb. Ct. R. Appendix 11 (Chapter 6, Article 14) Page 9 of 9 CC 16:2.41 Rev. Application for Approval of Monthly Budget of Guardian TO THE GUARDIAN AND/OR CONSERVATOR: This form is to be filed only with the Court. Do not send this form to the interested . Fill out one form for each ward, incapacitated person orprotected person. IN THE COUNTY COURT OF COUNTY, NEBRASKA THIS DOCUMENT IS CONFIDENTIAL AND SHALL NOT BE MADE PART OF THE COURT FILE OR PROVIDED TO THE PUBLIC PURSUANT TO NEB. CT.R. 247 6-1464. IN THE MATTER OF Ward/Incapacitated Person/Protected Person Case CONFIDENTIAL PERSONAL AND FINANCIAL INFORMATION FOR GUARDIANSHIPS AND CONSERVATORSHIPS Full name of the ward, protected or incapacitated person: Full date of birth of the ward, protected or incapacitated person: Full Social Security number of the ward, protected or incapacitated person: FINANCIAL INFORMATION OF THE WARD, PROTECTED OR INCAPACITATED PERSON Name(s) and address(es) of financial institution(s) Full account number(s) Date Signature(s) Print or Type Name(s) Bar Number and Firm Name (attorneys only) Street Address/P.O. Box City/State/ZIP Code Phone E-mail AddressInstructions: When parties are required to report personal and financial information to the court, the complete information shall be provided on Appendix 11 (CC 16:2.23). On pleadings or documents to be filed with the court, financial account numbers, dates of birth, and Social Security numbers, where required, should reference Appendix 11 11digits of the financial account when the account is reported on a pleading or document filed with the Court. American LegalNet, Inc. www.FormsWorkFlow.com