The State of New Hampshire COUNTY PROBATE COURT THE ESTATE OF OF DOCKET NUMBER: GUARDIAN'S/CONSERVATOR'S ACCOUNTING 1. The account for the period beginning Check if final account and ending 2. Telephone Guardian/conservator name Mailing address Telephone Co-guardian/conservator name Mailing address 3. Telephone Attorney name Firm name Mailing address 4. Account Summary (totals taken from the following page) TOTAL RECEIPTS $ TOTAL DISBURSEMENTS $ BALANCE IN HANDS OF FIDUCIARY $ ORDER … Account allowed. … Pending filing of If this is a final account, receipts for the balance must be filed within 30 days. Date: Judge AOC-002-003 (01/04) Page 1 of 4 American LegalNet, Inc. www.USCourtForms.com In Re: Estate of Summary of Receipts, Disbursements and Balance in Hands of Fiduciary (as per attached schedules): RECEIPTS *Inventory or Balance in Hand at Prior Accounting ...............Schedule A $ Net Gains (or losses) on Sales or Other Dispositions ...........Schedule B $ Income on all personal property, including dividends during accounting period..............................................Schedule C $ Cash accruing from sale of real estate ....................................Schedule D $ Cash collected on rents of real estate .....................................Schedule E $ Personal estate not inventoried/other receipts ......................Schedule F $ Cash received from other sources ..........................................Schedule G $ TOTAL RECEIPTS (Schedules A - G) ......................................................................$ DISBURSEMENTS Payments to the Ward on his/her behalf ................................Schedule 1 $ Taxes .........................................................................................Schedule 2 $ Administrative expenses .........................................................Schedule 3 $ Other expenditures ...................................................................Schedule 4 $ Fees (Show breakdown below.) ...............................................Schedule 5 $ Attorney fees $ Prior fees allowed to date: Attorney fees $ Fiduciary fees $ Fiduciary fees $ TOTAL DISBURSEMENTS (Schedules 1 - 5) ..........................................................$ *BALANCE IN HANDS OF FIDUCIARY (Total receipts less total disbursements)................. Schedule 6.................$ *These schedules must list each asset at both book value or cost and current value at the beginning (Schedule A) and end (Schedule 6) of the accounting period. Purposes of Accounting (i.e., any unusual events for which approval is sought) Are there any petitions or special requests pending, filed contemporaneously, or to be filed prior to the date of Yes No If yes, please specify. hearing on the account, relating to this account? Is an Information Schedule pursuant to Probate Rule 108(E) attached to this Accounting? Yes No Have all Federal and State Income Tax Returns of the ward for the period ending in this accounting been filed Yes No If no, attach explanation in Information Schedule. and the taxes connected therewith paid? Have all applicable physician's reports, guardian's reports, conservator's reports, or other reports required by statute or regulation or rule of court been filed, which were due between the time of filing the previous Yes No If no, attach explanation in the Information accounting and the filing of this accounting? Schedule. AOC-002-003 (01/04) Page 2 of 4 American LegalNet, Inc. www.USCourtForms.com In Re: Estate of Parties interested in the Accounting as of the Date of Filing; include name, capacity in which interested or relationship, and last known address. NAME ADDRESS RELATIONSHIP ASSENT / WAIVER OF NOTICE The undersigned, being all of the parties interested in the within account, hereby certify that we have examined the account, find it correct, and request that it be allowed without further notice to us. PRINT NAME BELOW LINE WRITE SIGNATURE ON LINE MAILING ADDRESS The undersigned hereby represent(s) that the above accounting is true and accurate to the best of his/her/their knowledge and belief, and certifies that a copy of this account has been sent to the ward as required by New Hampshire law. The undersigned further certifies that the following has been sent to all persons beneficially interested in this account and all parties appearing of record: a copy of the account which includes a notice to beneficially interested parties stating that the account may be approved unless a written objection is filed within 30 days after the date the account is filed in the probate court. Date: Guardian/Conservator Date: Guardian/Conservator THE STATE OF NEW HAMPSHIRE COUNTY DATE Subscribed and sworn to by the above named guardian/conservator(s) that all matters herein contained are true to his/her/their best knowledge and belief. Before me, My Commission Expires Affix Seal Justice of the Peace/Notary Public ATTENTION BENEFICIALLY INTERESTED PARTIES This Account may be approved by the probate court unless a written objection, containing the specific factual or legal basis for the objection, is filed within 30 days after the date the Account is filed in the probate court. Failure to file an objection may forfeit your right to a hearing concerning the Account or your objection, and the probate court may then act without a hearing or any further notice to you. AOC-002-003 (01/04) Page 3 of 4 American LegalNet, Inc. www.USCourtForms.com In Re: Estate of Probate Court Rule 108(E). The account shall show significant transactions that do not affect the amount for which the fiduciary is accountable. 1. The schedule listing such transactions shall consist of an information schedule, which shall be set forth at the end of the other schedules required in an account, setting forth each transaction by a separate number. 2. All changes in investments not reflected as gains or losses reported on other schedules of receipts shall be listed. These would include, but not be limited to, stock dividends; stock splits; changes in name; exchanges; or reorganizations. 3. All new investments made within the accounting period, and in hand at the close thereof, shall be noted on the schedules of assets on hand at the close of the accounting period. Totally new investments, and increased or additional investments in the same investment as shown on the schedules of assets on hand at the beginning of the account period of the account, shall be separately designated or annotated. 4. With regard to book accounts, notes or installment obligations (whether secured or not), detail regarding collections or payments shall be provided to permit reconciliation of the balances shown on schedules of assets on hand at the beginning and the close of the accounting period. 5. The fiduciary shall also report on the information schedule the details of any events causing or resulting in a change in the manner, method or course of the fiduciary's administration. Such events would include, but not be limited to, death of an interim income beneficiary; shifting enjoyment of the income to another beneficiary; death of a remainderman during the course of administering an estate; or a beneficiary reaching a designated age, after which time the beneficiary has a right to mandate partial withdrawals of principal. AOC-002-003 (01/04) Page 4 of 4 American LegalNet, Inc. www.USCourtForms.com