1 2 3 4 5 6 7 8 IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON IN AND FOR THE COUNTY OF KING 9 10 11 12 13 14 15 16 17 In the Guardianship of: ________________________________, An Incapacitated Person. ) ) ) ) ) ) Case No.: GUARDIAN’S REPORT AND ACCOUNTING (ANR) NOTICE: This Form is to be used if the estate has over $80,000.00 in assets. If you need more room to answer any item, please attach an additional page. 1. Date of Appointment and Reporting Period: The Guardian was appointed on _____________________. This Report covers the period from ___________________ 18 through ___________________. The closing date for all reports is (anniversary date of 19 appointment) _____________________, and the Guardian is required to file reports within 20 90 days of that date. The Guardian is to file a report every [ 21 months. 22 2. Continued Certification of Qualifications: The Guardian hereby certifies under penalty 23 24 25 26 ] 12, [ ] 24, [ ] 36 of perjury that they are over the age of eighteen, of sound mind, and has never been convicted of a felony or a misdemeanor involving moral turpitude, filed personal bankruptcy or been removed as a fiduciary in any proceeding for cause. (Please explain the circumstances if any you do not meet any of the conditions above.) __________________________________________________________________________ GUARDIAN’S REPORT AND ACCOUNTING-1 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 __________________________________________________________________________ 2 __________________________________________________________________________ 3 3. Scope of Guardianship: (Check all boxes that are appropriate.) 4 [ ] Full Guardianship of the Person [ ] Limited Guardianship of the Person [ [ ] The Incapacitated Person is a beneficiary of a Trust, which was approved by the 5 6 [ ] Full Guardianship of the Estate ] Limited Guardianship of the Estate Court or is subject to court supervision. The Trustee’s name, address, and court case no. are: 7 ______________________________________________________. 8 4. Contact Information for Incapacitated Person, Guardian and Standby Guardian: 9 Incapacitated Person 10 Mailing Address: 12 City, State & Zip: 13 Telephone Number: 14 Fax Number: 15 Standby Guardian Full Name: 11 Guardian Email Address: 16 17 5. Interested Parties: (List each person who has filed a Request for Special Notice of 18 Proceedings and those whom the Court has designated to receive copies of reports.) 19 Name 20 Mailing Address Relationship to Incapacitated Person 21 22 23 24 /// 25 /// /// 26 GUARDIAN’S REPORT AND ACCOUNTING-2 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 6. Interested Governmental Agencies: (Check all boxes that are appropriate.) 2 [ 3 Notice must be provided to the Department of Veteran Affairs, Henry M. Jackson Federal 4 Building, 915 Second Avenue, Seattle, WA 98174 fifteen days prior to filing this Report 5 6 ] The Incapacitated Person is a veteran who has served in the United States Military. with the Court. [ ] The Incapacitated Person is receiving Medicaid long-term funded care from the Department of Social and Health Services. Fees and costs of the guardian or the guardian’s 7 attorney are being sought as an adjustment to the Incapacitated Person’s amount of 8 participation. Notice must be provided to the Department of Social and Health Services 9 regional administrator of the program that is providing services to the Incapacitated Person 10 ten days prior to filing this Report with the Court. 11 7. Personal Care Plan: (To be filled out by all Guardians of the Person.) 12 a. Status. The Incapacitated Person is now _____ years of age. [ ] The Guardian believes that the Incapacitated Person is receiving satisfactory care 13 OR 14 [ 15 _______________________________________________________________________. 16 b. Change in Residence. The following changes in residence of the Incapacitated 17 18 19 20 ] the Guardian has the following concerns for which a change is requested Person occurred during the reporting period: ______________________________. c. Medical Condition. The medical condition of the Incapacitated Person is (list all disabilities and changes that occurred during the report period): __________________________________________________________________. d. Mental Condition. The mental condition of the Incapacitated Person (list diagnosis, 21 if any, and changes that occurred during the report period): 22 __________________________________________________________________. 23 e. Changes in Incapacitated Person’s Functional Ability. A description of changes, 24 if any, in the functional abilities of the Incapacitated Person: 25 __________________________________________________________________. 26 GUARDIAN’S REPORT AND ACCOUNTING-3 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 f. Activities of the Guardian Taken on Behalf of the Incapacitated Person. The 2 following is a description of the activities in which the Guardian has engaged for the 3 benefit of the Incapacitated Person: ____________________________________. 4 5 6 7 g. Description of Recommended Changes in Scope of Authority of Guardian. The scope of authority of the Guardian [ ] remains the same, OR [ ] should be changed as follows: _______________________________________. h. Names of Professionals Who Have Aided the Incapacitated Person. The 8 following professionals have assisted the Incapacitated Person during the period 9 covered by this report: ______________________________________________. 10 i. Guardian’s Plan for Future Care. The Guardian’s care plan, [ same, OR [ 11 12 13 14 15 16 17 ] remains the ] is changed as follows: __________________________________. 8. Estate Information:(To be filled out by all Guardians of the Estate. If you serve as Guardian of the person only, you do not have to complete the following section. Please make sure that you have signed where indicated below.) a. Benefits Received. The Guardian receives the following benefits on behalf of the Incapacitated Person: [ ] SSDI/SSA; [ ] SSI; [ ] Medicaid; [ ] Medicare; [ ] Copes; [ ] TANF; [ ] HUD; [ ] Food Stamps; [ ] GAU; [ ] Public Assistance; [ ] VA; [ ] CSA; [ ] Other--Specify: ________________. b. Bond/Blocked Accounts. There is $_______________ in unblocked accounts and 18 $_______________ in blocked financial accounts. The Guardianship bond issued by 19 ______________________________ identified by bond number _______________, and 20 is in the amount of $_______________. 21 /// 22 /// 23 /// 24 25 26 GUARDIAN’S REPORT AND ACCOUNTING-4 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 Total Assets at Market Value as of the beginning of review period $______________. 2 Income Received from All Sources (Do not include new assets purchased) 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 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) $ $ $ $ $ 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 $ $ $ $ $ $ $ $ $ $ $ Healthcare Expenses: Medical/Dental Pharmaceutical Medical Transportation Health Insurance Outside Case Management Fees Other (Specify): $ $ $ $ $ $ GUARDIAN’S REPORT AND ACCOUNTING-5 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 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): $ $ $ $ $ $ $ $ Residential Real Property Expenses: 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): Total Disbursements: Adjustments to Market Value of Estate: Addition of Assets/(Liabilities) Not Previously Reported (Do not use this section for assets purchased) 21 22 Deletion or Reduction in Value (Assets)/Liabilities: (Listed on previous accounting) 23 $ $ $ $ $ $ $ $ $ $ $ $ $ $ _______________ $ $ $ $ 24 25 26 GUARDIAN’S REPORT AND ACCOUNTING-6 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 Gifts Received/(Made): 2 3 4 5 Date of Court Order Authorizing Net Gains/(Losses) from Sales of Assets: $ $ $ $ 7 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) 8 Total Adjustments to Market Value of Estate: 9 Ending Balance at Market Value, as of (mm/dd/yyyy)__________:$ _______________ 6 10 ASSETS: 12 Description: 13 Accounting: $ _______________ 8. Balance Sheet for the Guardianship/Trust Estate 11 $ $ $ $ 14 15 16 17 18 19 20 21 22 23 24 Real Property: Cost Basis at End of Accounting: Date: Market Value at Start of Accounting: Date: Market Value at End of Accounting: Date: $ $ $ $ $ $ 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) $ $ $ $ $ $ $ $ $ 25 26 GUARDIAN’S REPORT AND ACCOUNTING-7 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 3 Personal and Other Property: (Household Goods, Vehicles, Burial Plots, funeral Plans, Life Insurance) $ $ $ $ $ $ $ $ $ 4 Total Assets: 1 2 5 6 7 8 9 10 11 12 LIABILITIES: Total Liabilities: $ $ $ $ $ $ $ $ $ $ $ $ I CERTIFY 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 AND ACCOUNTING AND ALL ATTACHMENTS HERETO ARE TRUE AND CORRECT. Signed at ________________, Washington, ___________, ____200__. 13 14 15 16 17 Signature Printed Name Address Telephone/Fax Number City, State, Zip Code Email Address 18 19 20 21 22 23 24 25 26 GUARDIAN’S REPORT AND ACCOUNTING-8 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com