ACCOUNTING SUMMARY FORM #3 FOR PROFESSIONAL GUARDIANS AND TRUSTEES (Estates over $80,000.00 in Liquid Assets) 9. Estate Information For Accounting Period starting __________________ and ending ____________________. A. Total Assets at Market Value as of the beginning of review period $________________. Income Received from All Sources (do not include new assets purchased) Wages & Benefits Wages Social Security Retirement Benefit Disability Health Insurance Benefits Other (Specify): CURRENT MONTHLY BENEFIT TOTAL RECEIVED $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Interest & Dividends List account and amount received: Other Receipts List source and amount received: B. Total Income: Disbursements and Outgoing Payments Personal Living Expenses Housing/Facility/Rent Companion/Attendant Care Food and Groceries Incidentals/Clothing Utilities Phone/Cable Insurance Personal Allowance Auto and Transportation Other (Specify): $ _______________ TOTAL $ $ $ $ $ $ $ $ $ $ $ Guardian’s Report, Accounting, and Proposed Budget-Page 5 2001 Guardianship Forms American LegalNet, Inc. www.USCourtForms.com Healthcare Expenses Medical/Dental Pharmaceutical Medical Transportation Health Insurance Outside Case Management Fees Other (Specify): $ $ $ $ $ $ Guardian and Trustee Fees Guardian Fees Trustee Fees $ $ Professional Fees Paid to Others Guardian ad Litem Fees Attorney Fees: for Guardian Attorney Fees: for Asset Management Fees Bond Premium Medical Claims Assistance Accountant/Tax Preparation Fees Other (Specify): $ $ $ $ $ $ $ $ Real Property Expenses: Residence Maintenance & Repair Homeowners/Co-op Dues Property Taxes Mortgage Insurance Other (Specify): $ $ $ $ $ $ Investment Property Expenses $ Other Expenses Employment Tax Income Tax Payments Costs Advanced Bank/Service Fees Other (Specify): $ $ $ $ $ Guardian’s Report, Accounting, and Proposed Budget-Page 6 2001 Guardianship Forms American LegalNet, Inc. www.USCourtForms.com C. Total Disbursements $ _______________ Adjustments to Market Value of Estate Addition of Assets/(Liabilities) Not Previously Reported (Do not use this section for assets purchased) $ $ Deletion or Reduction in Value (Assets)/Liabilities Listed on previous accounting $ $ Gifts Received/(Made) Date of Court Order Authorizing $ $ Net Gains/(Losses) from Sales of Assets $ $ Unrealized Gains/(Losses) Increase/(decrease) in unrealized gain on securities Increase/(decrease) in market value of real property Increase/(decrease) in market value of personal property Other Adjustments (Specify) $ $ $ $ D. Total Adjustments to Market Value of Estate: $ _______________ E. Ending Balance at Market Value, as of __________________: $ _______________ (A+B+C+D) 10. Balance Sheet for the Guardianship/Trust Estate ASSETS Description Market Value on Start of Accounting Date: Market Value at End of Accounting Date: $ $ Accounting: Cost Basis at End of Accounting Date: $ $ $ $ Real Property Guardian’s Report, Accounting, and Proposed Budget-Page 7 2001 Guardianship Forms American LegalNet, Inc. www.USCourtForms.com Receivables (Mortgages, Liens, Notes payable to the Incapacitated Person, the Estate, or Trust) $ $ $ $ $ $ Blocked Liquid Assets (Investment Accounts, Stocks, Bonds, Securities, IRA, Cash in Court Blocked Accounts) $ $ $ $ $ $ $ $ $ Unblocked Liquid Assets (Investment Accounts, Stocks, Bonds, Securities, IRA, Cash) $ $ $ $ $ $ $ $ $ Personal and Other Property (Household Goods, Vehicles, Burial Plots, funeral Plans, Life Insurance) $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL ASSETS: $ $ $ $ $ $ $ $ at Cost Basis $ at Market Value $ at Market Value LIABILITIES TOTAL LIABILITIES: 11. NET TOTAL ESTATE: Guardian’s Report, Accounting, and Proposed Budget-Page 8 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 9 2001 Guardianship Forms American LegalNet, Inc. www.USCourtForms.com