FORM #567GC-SF (01/2019) Page 1 of 4 62-5-416 STATE OF SOUTH CAROLINA ) ) COUNTY OF ) ) ) ) IN THE MATTER OF: ) PROBATE COURT US E ONLY ) , ) CASE NUMBER - GC - - a protected person. ) ) CONSERVATOR REPORT ) ANNUAL REPOR T 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 undersigned Conservator submits this Conservator Report covering the period from (mm/dd/yy) through (mm/dd/yy). 2. Does the Protected Person still require a conservatorship? YES NO Explain your answer. 3. Should limited or expanded in any way? YES NO Explain your answer. 4. 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.) 5. ACCOUNTING SUMMARY CALCULATION SUMMARY 5a. BEGINNING BALANCE From Inventory & Appraisement ( Form #550 GC ) OR Amount from Line 5(e) in the most recent Conservator Report) $ 5b. PLUS: Total Receipts $ 5c. SUBTOTAL (add Line 5a to 5b) $ 5d. LESS: Total Disbursements $ 5e. ENDING BALANCE (subtract Line 5d from 5c) $ American LegalNet, Inc. www.FormsWorkFlow.com FORM #567GC-SF (01/2019) Page 2 of 4 62-5-416 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 5b ) $ TOTAL DISBURSEMENTS (Line 5d ) $ 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-SF (01/2019) Page 3 of 4 62-5-416 6. List 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 ( Provide in form except those held with rights of survivorship, to include, but not limited to Protected land. ) INVESTMENTS ( Provide in form ation on all conservatorship restricted accounts, stocks, bonds, notes, receivables, checking and savings accounts, certificates of deposit, mutual funds, retirement accounts, etc .) MOTOR VEHICLES ( Provide in form , either individually or jointly with another owner(s) . ) OTHER ASSETS ( Provide in form ation 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 .) 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. 7. Does the Protected Person have sufficient mental capacity to understand this Report? YES NO If yes, you must provide a copy of this Report to the Protected Person. 8. Does the Protected Person reside with his/her parent(s)? YES NO If yes, you must provide a copy of this Report to his/her parent(s). 9. Does the Protected Person have a Guardian(s) appointed by this Court? YES NO If yes, you must provide a copy of this Report to his/her Guardian(s). 10. contact information changed since the last Report? YES NO If yes, please provide updated contact information for him/her below. Print Name: Address: Preferred Telephone: Secondary Telephone: Email: American LegalNet, Inc. www.FormsWorkFlow.com FORM #567GC-SF (01/2019) Page 4 of 4 62-5-416 PROOF OF DELIVERY On the day of , 20, I mailed or delivered this Conservator Report to all persons required to receive a copy of this Report pursuant to S.C. Code Ann. 247 62-5-416(C) and any Orders of this Court. Delivery was accomplished by the following method (check appropriate box(es)): personal delivery ordinary first-class mail certified mail registered mail commercial delivery NAME ADDRESS VERIFICATION The Conservator being sworn, states that the facts set forth in the foregoing Conservator Report are true and SWORN to before me this day of , 20 . Print Name: Address: Print Name: Preferred Telephone: Notary Public for: Secondary Telephone: (State) Email: My Commission Expires: (Date) SWORN to before me this day of Co - , 20 . Print Name: Address: Print Name: Preferred Telephone: Notary Public for: Secondary Telephone: (State) Email: My Commission Expires: (Date) PLEASE CHECK THIS BOX IF THE CONTACT INFORMATION FOR THE CONSERVATOR HAS CHANGED SINCE THE LAST REPORT. American LegalNet, Inc. www.FormsWorkFlow.com