FORM #567GC-LF (01/2019) Page 1 of 7 62-1-112, 62-1-201, 62-1-304, 62-5-101, 62-5-105, 62-5-306, 62-5-401, 62-5-409, 62-1-414, 62-5-416, 62-5-422, 62-5-423, 62-5-428 STATE OF SOUTH CAROLINA ) ) COUNTY OF ) ) ) ) IN THE MATTER OF: ) PROBATE COURT USE ONLY ) , ) CASE NUMBER - GC - - a protected person. ) ) CONSERVATOR REPORT ) ANNUAL REPORT AMENDED ANNUAL REPORT # INTERIM REPORT REQUIRED BY COURT ORDER FINAL REPORT WITH APPLICATION/ PETITION FOR DISCHARGE NOTE: In addition to completing this form, if you seek Court action, you must file a pleading requesting relief. 1. The Current Reporting Period for this Report is: from (mm/dd/yy) to (mm/dd/yy). 2. YES NO (If YES, please provide updated contact information for him/her below.) Print Name: Address: Preferred Telephone: Secondary Telephone: Email: 3. Does the Protected Person still require a conservatorship? YES NO Explain your answer. 4. Should expanded in any way? YES NO Explain your answer. 5. Should changes be made to the current conservatorship financial plan (if one is in place)? YES NO NO FINANCIAL PLAN IN PLACE (If YES, then please file an amended financial plan with your recommended changes.) 6. Have criminal charges been filed or convictions entered against the Conservator since the most recent Report? YES NO Explain: 7. Are there any joint interests or co-ownerships in assets or businesses involving the Conservator and the Protected Person? If yes, Explain in detail: American LegalNet, Inc. www.FormsWorkFlow.com FORM #567GC-LF (01/2019) Page 2 of 7 62-1-112, 62-1-201, 62-1-304, 62-5-101, 62-5-105, 62-5-306, 62-5-401, 62-5-409, 62-1-414, 62-5-416, 62-5-422, 62-5-423, 62-5-428 8. Are the assets in the estate sufficient to provide for his/her health, education, maintenance, and support and that of his/her dependents? YES NO Explain your answer: PART A: FINANCIAL INFORMATION Section 1: Estate Protection: Th is e state has the following protect ion (Check one): 9. A surety bond in the amount of $ is with bonding company, and is current. There is a restricted account agreement with financial institution. Another form of protection: There are no protective arrangements in place because: 10. Is the form of protection sufficient to cover all unrestricted assets? YES NO. Explain: 11. Professional conservators must confirm security is current and adequate. Have you filed an Affidavit of Conservator Regarding Bond (FORM #544GC)? YES NO. 12. The Conservator is requesting a change to the surety bond/other protection and is filing a motion with the Court. Section 2 : Other Financial Information (Attach copies of applicable document s ). 13. Is anyone involved in this conservatorship a party to a lawsuit ? YES NO If yes, answer the following: NAME: ( Conservator, Protected Perso n ) Plaintiff Defendant Location of Filing Represented by Docket/Case No. Amount of Suit Possible Completion Date Subject of Suit $ 14. Has the C onservator or any entity to which it has a fiduciary duty filed for bankruptcy ? YES NO If yes, answer the following: Date Filed Date Dismissed Date Discharged Petition/Case No. Location Filed 15. Will the Protected Person YES NO If yes, explain and prepare a Supplemental Inventory and Appraisement after the assets are received. Describe asset and when received: Anticipated amount to be received When will it be received? 15a. Is the Protected Person the beneficiary of a life insurance policy? YES NO If YES , answer Question 15. If NO , skip to Question 16. 15b. I nsuranc e Company Name & Address 15c. Policy Number(s) 15d. Owner of Policy 15e. Current Cash Value $ $ $ 15f. Outstanding Loan Balance $ $ $ 15g. Total Available Cash ( Subtract amounts on L ine 1 5f from L ine 1 5 e and include amounts from any attachments). NOTE: policies need NOT be converted to cash, only considered/reported $ American LegalNet, Inc. www.FormsWorkFlow.com FORM #567GC-LF (01/2019) Page 3 of 7 62-1-112, 62-1-201, 62-1-304, 62-5-101, 62-5-105, 62-5-306, 62-5-401, 62-5-409, 62-1-414, 62-5-416, 62-5-422, 62-5-423, 62-5-428 16. Does the Protected Person have a safe deposit box ? If YES , answer the following YES NO Location (Name, address and box number(s): Contents Value $ PART B: ACCOUNTING Section 1 : Liquid Assets 17. CASH ON HAND Total $ 18. PERSONAL BANK ACCOUNTS Include all checking accounts, savings accounts , online and mobile (e.g., PayPal) accounts, money market accounts, savings accounts, and stored value cards (e.g., payroll cards, government benefit cards, etc.) Type of Account Full Name & Address (Street, City, State, Zip) of Bank, Savings & Loan, Credit Union or Financial Institution Account Number (l ast 4 digits only ) Account Balance As of (mm/dd/yyyy) 18 a . $ 18 b . $ 18 c . $ 18d . $ 18e . $ 18f . $ 18g. Totals from additional pages $ 18 h . Total funds IN BANKS (Add lines 1 8 a through 1 8 g ) $ 18 i . Total LIQUID ASSETS (Add line 1 7 and line 1 8 h ) $ Complete this detail for ALL bank accounts. Attach additional pages if needed to include all bank accounts, enter the total from additional pages at Line 18g. For investments go to Schedule B; for Miscellaneous Personal Property go to Schedule F; for Rental Income go to Schedule C. Section 2: Accounting Summary of Receipts and Disbursements 19. ACCOUNTING SUMMARY CALCULATION SUMMARY 19 a. BEGINNING BALANCE From Inventory and Appraisement (Form #550 G C) OR Amount from Line 19 (e) in the most recent $ 19 b. PLUS: Total Receipts $ 19 c. SUBTOTAL (Add Line 19a to 19 b) $ 19 d. LESS: Total Disbursements $ 19e. ENDING BALANCE (Subtract Line 19d from 19c) $ American LegalNet, Inc. www.FormsWorkFlow.com FORM #567GC-LF (01/2019) Page 4 of 7 62-1-112, 62-1-201, 62-1-304, 62-5-101, 62-5-105, 62-5-306, 62-5-401, 62-5-409, 62-1-414, 62-5-416, 62-5-422, 62-5-423, 62-5-428 RECEIPTS DISBURSEMENTS (Assets received by the Protected Person this year.) (Assets paid out from the Protected Person's funds this year.) Description of Receipt Amount Description of Disbursement Amount TOTAL REC EI PTS (LINE 19 b ) $ TOTAL DISBURSEMENTS (Line 19 d ) $ NOTE: IF THE SPACE PROVIDED IS NOT SUFFICIENT TO ANSWER THE QUESTIONS ABOVE, PLEASE COMPLETE YOUR ACCOUNTING ON A SEPARATE SHEET OF PAPER AND ATTACH. American LegalNet, Inc. www.FormsWorkFlow.com FORM #567GC-LF (01/2019) Page 5 of 7 62-1-112, 62-1-201, 62-1-304, 62-5-101, 62-5-105, 62-5-306, 62-5-401, 62-5-409, 62-1-414, 62-5-416, 62-5-422, 62-5-423, 62-5-428 Section 3 : Non - Liquid Assets 20. INVESTMENTS Include stocks, bonds, mutual funds, stock options, certificates of deposit (CDs), Pre - paid burial (cash value if revocable; death benefit value if irrevocable) , and retirement assets such as IRAs, Keogh, and 401(k) plans. Type of Investment or Fina ncial Interest Type of Investment or Financial Interest Full Name & Address (Street, City, State, Zip) of Company Current Value Loan Balance (if applicable) a s of (mm/dd/yyyy) Equity Value minus Loan 2 0 a . 20 b . 20 c . 20 d . Total Equity (Add lines 2 0 a through 2 0 c and amounts from any attachments) $ PART C: LIST OF ASSETS & LOCATION Section 1: Annual Report of Assets 21. What are the current assets of the Protected Person managed by the Conservator: DESCRIPTION OF ASSET LOCATION OF ASSET OR NAME OF FINANCIAL INSTITUTION CURRENT FAIR MARKET VALUE COVERED BY INSURANCE? REAL PROPERTY ( , individually or jointly , to include, but not limited to ) INVESTMENTS ( Provide information on all conservatorship restricted accounts, stocks, bonds, notes, receivables, checking and savings accounts, certificates of deposit, mutual funds, retirement accounts, etc. ) MOTOR VEHICLES ( , individually or jointly . ) OTHER ASSETS ( Provide information on all other assets owned by the Protected Person including, but not limited to: business interests, home furnishings, collections, boats, recreational vehicles, jewelry, firearms, etc. ) 22. Have you become aware of additional assets owned by the Protected Person not listed on the Inventory and Appraisement? Yes No. Explain: If YES, you MUST file an Amended Inventory and Appraisement (Form #550GC). American LegalNet, Inc. www.FormsWorkFlow.com FORM #567GC-LF (01/2019) Page 6 of 7 62-1-112, 62-1-201, 62-1-304, 62-5-101, 62-5