ACCOUNTING SUMMARY FORM #1 – GENERAL PURPOSE FOR NON-PROFESSIONAL GUARDIANS (Estates over $80,000.00 in liquid assets) 9. Estate Information For Accounting Period starting ____________________ and ending ___________________. Item # Description Value at Beginning of Accounting: Date: ___________ Value at End of Accounting: Date: __________ Difference Real Estate Bank Accounts and Investments (Cash, Checking, Savings, CD’s, Money Market, Stocks, IRA’s) Money Owed TO the Incapacitated Person (Mortgages, Contracts, Promissory Notes Payable to the Incapacitated Person) Furniture, Vehicles, Boats, and Other Personal Property 10. Total Value of Assets Liabilities (List all debts or obligations of the Incapacitated Person and the Estate) 11. Total of Liabilities 12. Net Totals (Item 10 minus Item 11) Guardian’s Report, Accounting, and Proposed Budget-Page 5 2001 Guardianship Forms American LegalNet, Inc. www.USCourtForms.com 13. Income Received From All Sources During the Reporting Period a. b. c. d. e. f. g. Wages Social Security Retirement Benefits Disability Health Insurance Benefits Other Monthly Income Gain on Sale of Asset: Asset: Asset: h. Interest on Certificate(s) of Deposit i. Income on Mutual Funds j. Savings Account Interest k. Money Market/Checking Account Income l. From Trust or Spousal Maintenance m. Adjustment for Increase in Value of: n. Adjustment for Increase in Value of: o. Other: 14. Total Income Current Monthly Benefit $ $ $ $ $ $ $ Total Received $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 15. Disbursements and Outgoing Payments Personal Living Expenses a. Housing (Rent/Mortgage) at: b. Heat/Lighting/Water/Sewer/Cable/Telephone c. Household Maintenance d. Food and Household Supplies e. Clothing f. Personal Care and Services (Other than Medical Attendants) g. Insurance for: h. Allowance or Money Given Directly to Incapacitated Person i. Auto and Transportation j. Travel k. Other: Healthcare Expenses a. Health Insurance Premium $ $ $ $ $ $ $ $ $ $ $ $ Guardian’s Report, Accounting, and Proposed Budget-Page 6 2001 Guardianship Forms American LegalNet, Inc. www.USCourtForms.com b. c. d. e. f. g. Doctor Fees Hospital and Health Care Providers Prescription and Pharmacy Medical Transportation Visiting Nurse/Companion Services Other: Professional Fees a. Guardian Fees b. Attorney Fees for Guardian c. Attorney Fees for Petitioner d. Guardian ad Litem Fees and Costs e. Trustee Fees f. Bond Premium g. In-Home Services h. Accounting Fees i. Other: Other Expenses a. Subscriptions b. Bank Charges c. Federal Income Tax d. Gifts e. Adjustments for Decrease in Value of: f. Adjustments for Decrease in Value of: g. Other: 16. Total Disbursements Outgoing From Incapacitated Person’s Estate 17. Net Total of Income and Disbursements (Item 14 minus Item 16) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Guardian’s Report, Accounting, and Proposed Budget-Page 7 2001 Guardianship Forms American LegalNet, Inc. www.USCourtForms.com I certify (or declare) under penalty of perjury under the laws of the State of Washington that to the best of my knowledge the statements in this Guardian’s Report, Accounting, and Proposed Budget and attached Accounting Summary are true and correct and hereby petition the Court for approval. SIGNED AT ____________________, WASHINGTON THIS _______ DAY OF ___________________, 200__. Signature of Guardian Printed Name of Guardian, WSBA/CPG# Address Telephone/Fax Number City, State, Zip Code Email Address Guardian’s Report, Accounting, and Proposed Budget-Page 8 2001 Guardianship Forms American LegalNet, Inc. www.USCourtForms.com