Nebraska State Court Form REQUIRED INVENTORY, AFFIDAVIT OF DUE DILIGENCE, AND CERTIFICATE OF MAILING CC 16:2.9 Neb. Ct. R. 2476-1443 Page 1 of 5 NOTICE: 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 IN THE COUNTY COURT OF COUNTY, NEBRASKA IN THE MATTER OF Ward/Incapacitated Person/Protected Person Case INVENTORYChecking Accounts Bank Name Account no.XXX- $ Bank Name Account no. XXX- $Savings Accounts Bank Name Account no.XXX- $ Bank Name Account no. XXX- $Certificates of Deposit 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 2 of 5 Inventory, Affidavit of Due Diligence, and Certificate of Mailing CC 16:2.9 Rev 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/protected person (If applicable): Card Name Account no.XXX- $ Card Name Account no. XXX- $ TOTAL: $ See attached (more information than above) 5.REAL PROPERTY (List location by address and value): Location Value $Value $ Value $ Value $ TOTAL: $ NOTICE: You must file your letters of Guardianship and/or Conservatorship with the Register of Deeds in any county where the ward/incapacitated person/protected person has real property or an interest in real property. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 5 6.AFFIDAVIT OF DUE DILIGENCE: I, , appointed guardian and/or conservator of (name) , swear or affirm that this Inventory, to the best of my (ward/protected person/incapacitated person) knowledge and belief, is true, correct, and complete and that I have done the following to determine the assets of the ward/incapacitated person/protected person: I further swear or affirm that this Inventory contains all property owned by the above-named ward/incapacitated person/protected person as of the date below and that I have examined the Inventory and Affidavit of Due Diligence, and to the best of my knowledge and belief, they are true, correct and complete. Date Signature(s) of Guardian(s) and/or Conservator(s) Print or Type Name of Guardian(s) and/or Conservator(s) Bar Number and Firm Name (attorneys only) Street Address/P.O. Box of Guardian(s) and/or Conservator(s) City/State/ZIP Code of Guardian(s) and/or Conservator(s) Phone(s) E-mail Address(es) State of ) en) ss. County of ) The foregoing instrument was acknowledged before me by , this Name of person certifying above day of , . Day Month Year Notary Public (signature of person taking acknowledgment) My commission expires: (title or rank) (serial number, if any) American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 5 CERTIFICATE OF MAILING TO THE GUARDIAN AND/OR CONSERVATOR: You need to complete andfile this form with the court showing that you mailed the required documents marked below to all the interested you list below. I, , swear or affirm, under the penalties of perjury, that I original Inventory and the required forms marked below with the court and 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: Inventory and Affidavit of Due DiligenceNotice of Interested Party (CC 16:2.10)Notice of Right to Object (CC 16:2.16) NAME(S) OF INTERESTED PERSON(S) ADDRESS(ES) See attached (more names and addresses than above) Ward/Incapacitated Person/Protected Person Case Date Signature(s) of Guardian(s) and/or Conservator(s) Print or Type Name of Guardian(s) and/or Conservator(s) Bar Number and Firm Name (attorneys only) Street Address/P.O. Box of Guardian(s) and/or Conservator(s)City/State/ZIP Code of Guardian(s) and/or Conservator(s) Phone E-mail Address American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 5 *Interested persons are defined as:children and spouses;future heirs if the ward/incapacitated person/protected person would die without leaving a validwill (brothers and sisters who are adults, grandparents, etc.);a trustee of any trust executed by the ward/incapacitated person/protected person;/protecmost recent will;after death of the ward/incapacitated person/protected person, interested person also includes heirs in an intestate devisees in atestate estate;any governmental agency paying benefits on behalf of the ward/incapacitated person/protectedperson; 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/protected 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/protected person. American LegalNet, Inc. www.FormsWorkFlow.com