STATE OF NEBRASKA FORM NO. 16:2 3/91 rev. page 1 of 2 pages CASE NUMBER Inventory IN THE MATTER OF THE GUARDIANSHIP/CONSERVATORSHIP OF (ward) 1. PERSONAL PROPERTY: Checking Accounts Bank Name Account no. Bank Name Account no. Bank Name Account no. $ $ $ $ $ $ Savings Accounts Bank Name Account no. Bank Name Account no. Bank Name Account no. $ $ $ $ $ $ Certificates of Dep. Bank Name Account no. Bank Name Account no. Bank Name Account no. $ $ $ $ $ $ Stocks and Bonds $ Vehicles $ Household goods and furnishings $ Other: $ TOTAL: $ 2. JOINTLY HELD PROPERTY: With whom What $ With whom What $ TOTAL: $ American LegalNet, Inc. www.FormsWorkflow.com 3. INCOME (Monthly): Social Security $ Supplemental Security Income $ Veterans Administration Benefits $ Company Pension $ Interest From where $ Dividends From where $ Other: $ TOTAL: $ 4. REAL PROPERTY (List location by address and value): STATE OF NEBRASKA ) ) ss. COUNTY OF ) The undersigned Conservator of this estate, on oath states that this inventory contains all property owned by the above-named ward as of the date below and that said inventory is complete and accurate so far as the undersigned is informed. DATE: GUARDIAN/CONSERVATOR: Subscribed and sworn to before me this day of , (Notary Public) page 2 of 2 pages American LegalNet, Inc. www.FormsWorkflow.com .