FORM #550GC (01/2019) Page 1 of 6 62-5-415 STATE OF SOUTH CAROLINA ) ) COUNTY OF ) ) IN THE MATTER OF: ) PROBATE COURT USE ONLY ) , ) CASE NUMBER - GC - - ) a protected person. ) INVENTORY AND APPRAISEMENT ORIGINAL SUPPLEMENTAL # Conservator: The undersigned, being sworn, states: That the following schedules contain a complete and accurate inventory and appraisement of all real and personal property of this estate Conservator has estimated and/or appraised all listed property at its fair market value, according to the best of his/her knowledge, information and belief. Copies of this inventory have been sent to the following persons:* SWORN to before me this d ay of Conservator's Signature: , 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 - Conservator's Signature: , 20 . Print Name: Address: Print Name: Preferred Telephone: Notary Public for: Secondary Telephone: (State) Email: My Commission Expires: (Date) The gross fair market valuation of all assets, regardless of situs, should be given as of the date of appointment. List all out-of-state assets on appropriate schedules. A Supplemental Inventory should be utilized for correcting, adjusting, or adding to an original inventory. The type and amount of any encumbrances that may exist with reference to any item should be disclosed. RECAPITULATION Schedule A - Real Estate Schedule B - Accounts Schedule C - Anticipated Annual Receipts NOT INCLUDED Schedule D - Life Insurance Schedule E - Jointly Owned Property Schedule F - Other Miscellaneous Schedule G - Transfers Prior to I ncapacity Schedule H - Powers of Appointment Schedule I - Annuities TOTAL GROSS VALUE ENCUMBRANCES ( ) TOTAL NET WORTH *Within thirty (30) days following appointment, the original inventory shall be filed with the Probate Court. A copy must be provided to the protected person guardian, if any, and to any other persons the Court may direct. American LegalNet, Inc. www.FormsWorkFlow.com FORM #550GC (01/2019) Page 2 of 6 62-5-415 NOTE: WHEN COMPLETING THE FOLLOWING SCHEDULES, PLEASE REMEMBER TO LIST ALL ASSETS, REGARDLESS OF SITUS; ALL OUT-OF-STATE ASSETS MUST BE DISCLOSED. SCHEDULE A - Real Estate (If none, so state.) List interest in real property except those held with right of survivorship. (See Schedule E). If real property is income producing, report income on Schedule C. Item No. Description - Include location, tax map number and use made of property (e.g., rental, owner - occup ied) Property, insurance carrier & Amount of Insurance Type of ownership and Percentage Interest (e.g., fee simple, tenants in common) Fair Market value of Interest TOTAL SCHEDULE A (also enter under recapitulation, page 1) $ SCHEDULE B Accounts and Investments (If none, so state) List stocks, bonds, notes, receivables, checking and savings accounts, certificates of deposit, mutual funds, retirement accounts, etc. If investments produce income, report income on Schedule C. List investments held with right of survivorship on Schedule E. Item No. Description of Shares Include kind of investment, location and number Type of ownership and percentage interest Fair Market Value TOTAL SCHEDULE B (also enter under recapitulation, page 1) $ SCHEDULE C - Anticipated Annual Receipts (If none, so state.) List all income, including social security, workers compensation benefits, annuities, retirement interest income, rental income, alimony, disability benefits, dividends, royalties, etc. THIS SECTION NOT INCLUDED IN RECAPITULATION. Item No. Description When received (monthly, quarterly, annually, etc.) Annual Amount TOTAL SCHEDULE C ( also enter under recapitulation, page 1) $ (If more space is required, insert tax schedules or additional sheets of same size.) American LegalNet, Inc. www.FormsWorkFlow.com FORM #550GC (01/2019) Page 3 of 6 62-5-415 SCHEDULE D - Life Insurance owned by the Protected Person. (If Item No. Description - type, company, name, policy number, premium amount Insured Beneficiary Face Value Cash Value TOTAL CASH VALUE (also enter under recapitulation, page 1) $ $ Other Insurance - Health, Disability, Supplement, Long Term Care Item No. Description - type provided Company Name Policy Number Coverage Premium Amount When Payable SCHEDULE E - Property owned jointly with right of survivorship (if none, so state.) Item No. Description - include kind, location and co - owner(s) Appraised Value(s) Percentage Ownership Value of Protected TOTAL SCHEDULE E (also enter under recapitulation, page 1) $ (If more space is required, insert tax schedules or additional sheets of same size.) American LegalNet, Inc. www.FormsWorkFlow.com FORM #550GC (01/2019) Page 4 of 6 62-5-415 SCHEDULE F - Miscellaneous Personal Property - (If none, so state.) List tangible personal property items, title assets, employment bonus or award, interest in a partnership or unincorporated business, articles or collections having either artistic or intrinsic value, etc.) Item No. Description Location Is it Insured? If so, by who? Value of Protected TOTAL SCHEDULE F ( also enter under recapitulation, page 1) $ (If more space is required, insert tax schedules or additional sheets of same size.) SCHEDULE G -Transfers Within Three Years of Incapacity -Transfers intended to take effect at death. United States Government Bonds other incidents of ownership retained, life insurance transfers. Lifetime transfers of real property in which Incapacitated Person retains a life estate or other incidents of ownership. (If none, so state.) Item No. Description Value TOTAL SCHEDULE G (also enter under recapitulation, page 1) $ (If more space is required, insert tax schedules or additional sheets of same size.) American LegalNet, Inc. www.FormsWorkFlow.com FORM #550GC (01/2019) Page 5 of 6 62-5-415 SCHEDULE H - Powers of Appointment - Property, both real and personal, over which Incapacitated Person possesses a Power of Appointment whether Testamentary or otherwise. (If none, so state.) Item No. Description Value TOTAL SCHEDULE H (also enter under recapitulation, page 1) $ SCHEDULE I - Annuities (If none, so state.) Item No. Description & Name of Beneficiary Value TOTAL SCHEDULE I (also enter under recapitulation, page 1) $ (If more space is required, insert tax schedules or additional sheets of same size.) American LegalNet, Inc. www.FormsWorkFlow.com FORM #550GC (01/2019) Page 6 of 6 62-5-415 ENCUMBRANCES - (e.g., mortgages, liens, judgments, etc., but not general debts of the estate) - List specific assets encumbered Item No. Schedule & Item Number of the Encumbered Item (ex. Schedul e A, Item 1) Description & Amount TOTAL ENCUMBRANCES (also enter under recapitulation, page 1) $ (If more space is required, insert tax schedules or additional sheets of same size.) American LegalNet, Inc. www.FormsWorkFlow.com