PACKET CCONSERVATORSHIP ANNUAL REPORTING FORMS Who may use these forms: A person who has been appointed a conservator uses these forms to account to the court each year. These are the forms to be used whether or not some or all of the accounts are restricted. What are you reporting to the court: You are reporting all money received by you on behalf of the protected person and all expenses paid by you on behalf of the protected When are the forms to be used: You must complete the entire packet of forms and file them with the court every year from the date Letters of Appointment were issued. Your first year begins on the date Letters of Appointment are issued to you and ends one year later. You are required to file these forms each year, from that point forward. For example, if Letters of Appointment were issued to you on June 10, 2012, then your If these forms only are submitted and no fees are requested, then a hearing will not be automatically scheduled. A hearing will only be automatically scheduled if the court has any questions about the accounting or an interested person files an objection to the accounting. If you need additional copies of this packet, forms are available on the Supreme Court website: http://supremecourt.ne.gov/forms The cost of filing this pSpecific Instructions: This packet includes the following: Updated Inventory (Pages 1-3): You complete this portion of the packet by providing the account balance for each bank account and the account value for each brokerage account as of the last day of the reporting period. Accounting (Pages 4- ou must also provide an accountingAmerican LegalNet, Inc. www.FormsWorkFlow.com Certificate of Proof of Possession (Pages 6-7): You will need one Certificate for each bank or other financial institution. You will begin a portion of the Certificate, but the bank or other financial institution will finish the Certificate. Complete the case information on the Certificate, then take this form to the bank or other financial institution and ask a representative there to write in the account information, the balance in the account, and any interest paid. You should have the account balance confirmed as of the last day of the accounting. The representative from the bank or other financial institution must sign the Certificate in the presence of a notary public because his or her signature must be notarized. The original Certificate(s) must be filed with the court and copies mailed to the interested . Notice of Right to Object (Page 8): You must complete this form, file the original with the court and mail a copy to all interested . Certificate of Mailing (Pages 9-10): By filing this Certificate with the court you are informing the court that you have mailed copies of the forms listed the interested persons. You must also list the names and addresses of the interested persons you mailed the forms to on this form. The original must be filed with the court and a copy mailed to all interested . Personal and Financial Information for Guardianships and Conservatorships (Page 11): You need to complete this form by filling in the name of the protected person, his or her date of birth, social security number and the name and address of all banks or other financial institutions where the protected person has money. You must include full account numbers on this form. This form is filed with the court only. Do not send this form to the interested . American LegalNet, Inc. www.FormsWorkFlow.com Nebraska State Court FormREQUIRED CONSERVATORSHIP ANNUAL REPORTING FORMS PACKET C CC 16:2.35 Page 1 of 11 CC 16:2.35 Rev. Packet C - Conservatorship Annual Reporting Forms IN THE COUNTY COURT OF COUNTY, NEBRASKA IN THE MATTER OF Protected Person Case UPDATED INVENTORY, ACCOUNTING, CERTIFICATE OF PROOF OF POSSESSION, NOTICE OF RIGHT TO OBJECT, AND CERTIFICATE OF MAILING TO THE CONSERVATOR: 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 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 BondsVehiclesHousehold goods and furnishingsOther: $ $ $ $ TOTAL: $ American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 11 CC 16:2.35 Rev. Packet C - Conservatorship Annual Reporting Forms 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 protected person (If applicable) Card Name Account no.XXX- $ Card Name Account no. XXX- $ TOTAL: $ American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 11 CC 16:2.35 Rev. Packet C - Conservatorship Annual Reporting Forms 6.Please mark one of the following (A or B) and complete the additional questions, if any, for the section you marked: A) I do have possession or control of the protected money, assets,possessions or income (including social security or other benefits) AND myaccounting,certificate of proof of possession, and bank statements are filed with the court. B)I do not have possession or control of the protected person money, assets, possessions or income (including social security or other benefits). The person who haspossession or control of the protected person money, assets, possessions or income(including social security or other benefits) is: AND 1)I have talked to the person in charge of the protected personmoney, assets, possessions or income (including social security or other benefits) AND a)I am satisfied that the funds are being handled properly. b)I am not satisfied that the funds are being handled properly because 2)I have not assets, possessions or income (including social security or other benefits)because 7.Current address of the protected person: American LegalNet, Inc. www.FormsWorkFlow.com (If more space is needed, copy this form, number additional pages as page of , and attach) Page 4 of 11CC 16:2.35 Rev. Packet C - Conservatorship Annual Reporting Forms ACCOUNTING TO THE CONSERVATOR: Complete only if funds have been spent from or added to the protected included. Last four digits of account number: Beginning date of accounting: Ending date of accounting: Beginning Balance: Date Check Number Rec eived from/Paid to Purpose Amount received Amount paid Balance American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 11 CC 16:2.35 Rev. Packet C - Conservatorship Annual Reporting Forms I swear or affirm, under the penalties of perjury, that I have examined the Updated Inventory and Accounting, and to the best of my knowledge and belief, they are true, correct and complete. Date Signature(s) of Conservator(s) Print or Type Name of Conservator(s) Bar Number and Firm Name (attorneys only) Street Address/P.O. Box of Conservator(s) mark if new address City/State/ZIP Code of Conservator(s) Phone of Conservator(s) E-mail Address of Conservator(s) American LegalNet, Inc. www.FormsWorkFlow.com Page 6 of 11 CC 16:2.35 Rev. Packet C - Conservatorship Annual Reporting Forms CERTIFICATE OF PROOF OF POSSESSION TO THE CONSERVATOR: This form must be completed by the financial institution. It must be filed with the court, sent to all interested , and will be public information. For protection offinancial information, give only the last four digits of accounts and bond information on this form. Complete account and bond information must be provided on the Personal and Financial Information for Guardianships and Conservatorships form (CC 16:2.23). In the matter of the estate of ase numberName of uardian and/or onservator: Name and address of nstitution CERTIFIC