1 Form 4-998. Conservator222s report. [For use with Rule 1-140 NMRA] STATE OF NEW MEXICO COUNTY OF JUDICIAL DISTRICT In the matter of , No. a Protected Person. CONSERVATOR222S REPORT FINANCIAL SUMMARY Current Last Year Two Years Ago A.Net Asset Value of Previous Year222sReport (or Beginning Inventory if this isyour first report)$ B.Plus Income ( Total from Section II,below)$ C.Less Expenses ( Total from Section III,below)$ D.Plus additions or (minus) deletions toinventory during the year$ E.(Minus) additions or plus deletions todebt during the year$ F.Net Asset Value(A + B 226 C +/226 D +/226 E)$ Assets ( Sum Total from Section IV, below) $ Less Debts ( Sum Total from Section V, below) $ Net Asset Value (Line F) $ Please note: Fill out this financial summary after you have completed this entire report. Use the information that you enter in Sections II through V of this report and the information from the reports that you filed last year and two years ago. American LegalNet, Inc. www.FormsWorkFlow.com 2 REPORTING PERIOD. This report covers the dates beginning and ending . Is this a Final Report? 001 Yes 001 No If yes, please check the box that explains why you are filing a Final Report and fill in the requested information. 001 The Protected Person has died (attach a copy of the death certificate if available). Date and place of death: Instructions. If you were appointed conservator within the past ninety (90) days, do not use this form. The first report that you must file is a Conservator222s Inventory, Form 4-997 NMRA. The Conservator222s Inventory is due within ninety (90) days of your appointment. You must use this form, Form 4-998 NMRA, when you file a Conservator222s Report. The purpose of a Conservator222s Report is to give the court as complete a picture as possible of the current financial situation for the person under conservatorship, also called the Protected Person. 1.This Conservator222s Report is due as follows:a.You must complete and file this Conservator222s Report every year withinthirty (30) days of the anniversary date of your appointment asconservator.b.You must complete and file this Conservator222s Report within sixty (60)days of your resignation, removal, or termination as conservator.2.Please type or print clearly using ink.3.Complete all sections of this report.4.Attach additional pages if necessary.5.After completing this report, you must sign it under penalty of perjury.6.Copies of this report must be given to the Protected Person, the ProtectedPerson222s guardian if one has been appointed, and any other persons specified bythe court.7.Keep a copy of this report for your records.8.You must keep a copy of ALL of the Protected Person222s financial records forseven (7) years and make them available to the court upon request. American LegalNet, Inc. www.FormsWorkFlow.com 3 Name of personal representative, if appointed: Address: 001 The court has appointed a new conservator. Name of new conservator: Address and phone number of new conservator: 001 The court has issued an order ending the conservatorship. 001 Other (please explain): SECTION I - Information about the Protected Person. A.Protected Person222s name: B.Protected Person222s age: C.Protected Person222s physical address: Mailing address (if different): D.Protected Person222s telephone number(s) and other contact information:Home: Cell: Work: Fax: Email: E.Has a guardian also been appointed for the Protected Person?001 Yes 001 NoIf yes, name of guardian: Address: Phone: American LegalNet, Inc. www.FormsWorkFlow.com 4 F.Does the Protected Person have sole control over any money?001 Yes 001 NoIf yes, explain: G.Has the Protected Person222s residence changed in the past 12 months?001 Yes 001 NoIf yes, explain: H.Describe any significant actions you have taken as conservator regarding the ProtectedPerson222s financial condition during the reporting period. I.Describe any significant changes of circumstances for the Protected Person (financial,physical or mental health, living arrangements, etc.). J.Is the Protected Person the beneficiary of a trust? 001 Yes001 No If yes, what is the name of the trust? What is the current value of the trust? Who is the trustee? American LegalNet, Inc. www.FormsWorkFlow.com 5 What is the trustee222s contact information? K.Are the Protected Person222s funds kept in a separate account from the conservator222s funds?001 Yes 001 NoIf no, explain: SECTION II - Income. (Fill in only the boxes that apply to the Protected Person222s income; leave the other boxes blank) Description of each Income Source (Report only the income received by the Protected Person, not your income) Amount Received this Reporting Period Amount Received last year Amount Received two Years ago Social Security Benefits Social Security $ Social Security Disability Insurance (SSDI) $ Supplemental Security Income (SSI) $ Veterans Financial Benefits $ Trust Income $ Wages $ Worker222s Compensation Benefits $ Dividends Received $ Interest Income $ American LegalNet, Inc. www.FormsWorkFlow.com 6 Description of each Income Source (Report only the income received by the Protected Person, not your income) Amount Received this Reporting Period Amount Received last Year Amount Received two Years ago Refunds Tax Refunds $ Insurance Refunds $ Other Refunds (explain) $ Realized Gain/Loss on Sale of Asset $ Rental Income $ Royalty Income (oil, gas, etc.) Pension or 401(k) Distributions $ Annuity Income $ Alimony or Child Support $ Inheritance and Gifts Received $ Sale of Personal Property Not Listed on Inventory $ IRA Distributions $ Distribution from Tribal or Pueblo Government $ Life Insurance Proceeds $ Other (reverse mortgage, etc.) $ SECTION II TOTAL $ $ American LegalNet, Inc. www.FormsWorkFlow.com 7 SECTION III - Expenses. (Fill in only the boxes that apply to the Protected Person222s expenses; leave the other boxes blank) Description of each Type of Expense (money paid to anyone on behalf of the Protected Person or on behalf of his/her legal dependents) Expense this Reporting Period Expense one Year ago Expense two Years ago Nursing/Assisted Living Home $ In-Home Care $ Rent Payment $ Mortgage Payment Mortgage Interest $ Mortgage Escrow $ Homeowner222s Insurance if Not Paid by Escrow Account $ Property Tax if Not Paid by Escrow Account $ Utilities (Gas, Electric, Water, and Sewer) $ Cable/Satellite Television and/or Internet Service $ Cell and other Phone Service $ Transportation (including gasoline expenses) $ Medical, Dental, and Vision Treatment Costs Not Paid by Insurance (including co-pays and deductibles) $ Medical Supplies and Equipment $ Medications Not Paid by Insurance (including co-pays and deductibles) $ Credit Card Payments $ Food, Groceries, Dining $ American LegalNet, Inc. www.FormsWorkFlow.com 8 Description of each Type of Expense (money paid to anyone on behalf of the Protected Person or on behalf of his/her legal dependents) Expense this Reporting Period Expense one Year ago Expense two Years ago Clothing $ Recreation, Entertainment, Memberships $ Travel (Vacation, Family Visits, etc.) $ Household Goods and Electronics $ Personal Grooming $ Personal Spending Allowance $ Pet Care (Food, Veterinary Care, Kennel, etc.) $ Income Tax Total Federal Payments $ Total State Payments $ Home/Property Maintenance Costs (including housekeeping and yard service) $ Insurance Auto Insurance $ Medical Insurance $ Life Insurance $ Other Insurance (Long Term Care, Etc.) $ Court Approved Gifts $ Other Gifts or Charitable Donations $ Child/Spousal Support $ American LegalNet, Inc. www.FormsWorkFlow.com 9 Description of each Type of Expense (money paid to anyone on behalf of the Protected Person or on behalf of his/her legal dependents) Expense this Reporting Period Expense one Year ago Expense two Years ago Legal Fees $ Fees/Costs Paid to Conservator $ Fees/Costs Paid to Guardian $ Accounting Fees $ Court Costs $ Conservator222s Bond $ Case Management $ Other Expenses (describe) $ SECTION III TOTAL $ SECTION IV 226 Assets. (Fill in only the boxes that apply to the Protected Person222s assets; leave the other boxes blank) A.Are you holding cash on hand on behalf of the Protec