THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) Guardianship/Conservatorship of GUARDIAN'S/CONSERVATOR'S ACCOUNTING Original Amended 1. The and ending 2. Guardian/conservator name Mailing address Co-guardian/conservator name Mailing address 3. Attorney for Guardian/Conservator Firm name Mailing address 4. Account Summary (totals taken from the following page) TOTAL RECEIPTS TOTAL DISBURSEMENTS BALANCE HELD BY GUARDIAN / CONSERVATOR $ $ $ Telephone Bar ID # Telephone account for the period beginning Check if final account Telephone ORDER Account allowed. Account allowed pending filing of Account disallowed for the following reasons If this is a final account, receipts for the balance must be filed within 30 days. Date Judge American LegalNet, Inc. www.FormsWorkFlow.com NHJB-2160-P (03/25/2013) Page 1 of 4 Case Name: Guardianship/Conservatorship of Case Number: GUARDIAN'S/CONSERVATOR'S ACCOUNTING 5. RECEIPTS Schedule A ­ Inventory Total of Personal and Real Estate or Balance held at Prior Accounting * ..................... $ On a separate sheet of paper, list all the assets (including real estate) that were listed on the Inventory form. For accounts other than the first account, list each item included in Schedule 6 of the prior accounting. Schedule B ­ Net Gains (or losses) on Sales or Other Dispositions$ On a separate sheet of paper, list the Inventory value and sale price for each asset (other than real estate) sold, and show the difference between the two amounts. Also list the date of the sale. Note: A Motion and License to Sell Real Estate or Personal Property in Guardianship or Conservatorship (form NHJB-2164-P) is required to sell personal property belonging to the ward. Schedule C ­ Income on all personal property, including dividends, during accounting period ................................................ $ On a separate sheet of paper, list all income, including dividends and interest, received during this accounting period. List the source of income, the individual amounts and date each was received. Schedule D ­ Net gains (or losses) from sale of real estate ....... $ If real estate was listed on the Inventory, and has been sold during this accounting period, on a separate sheet of paper, list the address of the real estate, sale price, amounts deducted from sale price, amount received by the ward's estate, and the date of sale. Note: A Motion and License to Sell Real Estate or Personal Property in Guardianship or Conservatorship (form NHJB-2164-P) is required to sell real estate belonging to the ward. (May also attach a copy of the HUD settlement statement.) Schedule E ­ Cash collected on rents of real estate ................... $ If rent was collected on real estate during this account period, on a separate sheet of paper, list the amount collected and the months for which the rent was collected. Schedule F ­ Personal estate not inventoried/other receipts ...... $ On a separate sheet of paper, list any asset that was not listed on the Inventory with an explanation as to why it was not listed. Also list the description and value for each of the assets. Schedule G ­ Cash received from other sources ........................ $ On a separate sheet of paper, list all other contributions and income received by the ward's estate with a description including the date received, the source of the funds and the amount received. TOTAL RECEIPTS (Schedules A - G).......................................... Add the amounts in Schedules A through G. Also enter this amount on Page 1, #4. $ NHJB-2160-P (03/25/2013) Page 2 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Guardianship/Conservatorship of Case Number: GUARDIAN'S/CONSERVATOR'S ACCOUNTING 6. DISBURSEMENTS Schedule 1 ­ Payments to or for the Ward on his/her behalf ........ $ On a separate sheet of paper, list all payments made to or on behalf of the ward. For each payment, list the date paid, a description of the payment, to whom the payment was made and the amount paid. Schedule 2 ­ Taxes . ................................................................... On a separate sheet of paper, list any taxes paid on behalf of the ward, such as, income taxes, real estate/property taxes, etc. List the date paid, type of tax, to whom it was paid and the amount paid. $ Schedule 3 ­ Administrative expenses ........................................... $ Administrative expenses are all expenses incurred in administering the guardianship, such as court costs, bond premiums, etc. On a separate sheet of paper, for each expense, list the date paid, to whom it was paid, and the amount. Schedule 4 Total Fees (show breakdown below) ........................................... Attorney fees $ Prior fees allowed to date: Attorney fees $ Guardian fees $ Guardian fees $ $ Probate rules require fees to be shown in summary form. This summary is sufficient unless the Court requires further detail. Schedule 5 ­ Other expenditures .................................................... On a separate sheet of paper, list any other disbursements not listed in Schedules 1 through 4 above. List the amount disbursed, date it was disbursed and the name of the person receiving the disbursement. $ TOTAL DISBURSEMENTS (Schedules 1 - 5) .............................. Add the amounts in Schedules 1 through 5. Also enter this amount on Page 1, #4. 7. $ Schedule 6 - BALANCE HELD BY GUARDIAN / CONSERVATOR (Total Receipts less Total Disbursements) ................................... On a separate sheet of paper, list all the assets, including real estate, remaining in the estate of the ward and the value of each asset. Also enter this amount on Page 1, #4. * $ * These schedules must list each asset at both book value/cost and current market value at the beginning (Schedule A) and end (Schedule 6) of the accounting period. NHJB-2160-P (03/25/2013) Page 3 of 4 American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Guardianship/Conservatorship of Case Number: GUARDIAN'S/CONSERVATOR'S ACCOUNTING 8. Is an Information Schedule pursuant to Probate Division 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 and the taxes connected therewith paid? Yes No If no, attach explanation in Information Schedule. 9. 10. Have there been any changes to the parties interested in the Accounting or ha