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) NOTE: This form is to be used for estates valued at less than $80,000.00. 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 ___________________ through 18 ___________________. 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 he or she is 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. Personal Care Plan: (To be filled out by all Guardians of the Person.) 2 a. Status: The Incapacitated Person is now _____ years of age. 3 [ ] The Guardian believes that the Incapacitated Person is receiving satisfactory care OR 4 [ ] the Guardian has the following concerns for which a change is requested 5 ____________________________________________________________________. 6 b. Change in Residence: The following changes in residence of the Incapacitated 7 8 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): 9 10 11 __________________________________________________________________ d. Mental Condition: The mental condition of the Incapacitated Person (list diagnosis, if any, and changes that occurred during the report period): 12 13 __________________________________________________________________ e. Changes in Incapacitated Person’s Functional Ability: A description of changes, 14 if any, in the functional abilities of the Incapacitated Person: 15 __________________________________________________________________ 16 f. Activities of the Guardian Taken on Behalf of the Incapacitated Person: The following is a description of the activities in which the Guardian has engaged for the 17 18 19 20 benefit of the Incapacitated Person: _________________________________ g. Description of Recommended Changes in Scope of Authority of Guardian: The scope of authority of the Guardian [ ] remains the same, OR 21 [ ] should be changed as follows: _______________________________________ 22 h. Names of Professionals Who Have Aided the Incapacitated Person: The 23 following professionals have assisted the Incapacitated Person during the period 24 covered by this report: ______________________________________________ 25 26 i. Guardian’s Plan for Future Care. The Guardian’s care plan, [ same, OR [ ] remains the ] is changed as follows: __________________________________ GUARDIAN’S REPORT AND ACCOUNTING-3 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 7. Estate Information (To be filled out by all Guardians of the Estate. If you serve as 2 Guardian of the person only, you do not have to complete the following section. Please 3 make sure that you have signed where indicated below.) a. Interested Governmental Agencies: (Check each box that is applicable.) 4 [ 5 ] The Incapacitated Person is a veteran who has served in the United States Military. Notice must be provided to: The Department of Veteran Affairs, Henry M. 6 Jackson Federal Building, 915 Second Avenue, Seattle, WA 98174 fifteen days prior 7 to filing this Report with the Court. 8 [ 9 the Department of Social and Health Services. Fees and costs of the Guardian or the 10 Guardian’s attorney are being sought as an adjustment to the Incapacitated Person’s 11 amount of participation. Notice must be provided to the Department of Social and ] The Incapacitated Person is receiving Medicaid long-term funded care from Health Services regional administrator of the program that is providing services to 12 the Incapacitated Person ten days prior to filing this Report with the Court. 13 b. Benefits Received. The Guardian receives the following benefits on behalf of 14 the Incapacitated Person: [ ] SSDI/SSA; [ 15 Medicare; [ 16 GAU; [ 17 ] SSI; [ ] Medicaid; [ ] ] Food Stamps; [ ] Other-Specify:_______________ ] Public Assistance; [ ] HUD; [ ] VA; [ commencement of the Guardianship [ 19 ] CSA; [ ] ] is, or [ ] is not on file herein. An updated inventory is contained in this Report. 20 d. Bond/Blocked Accounts. There is $_______________ in unblocked accounts 21 and $_______________ in blocked financial accounts. The Guardianship bond 22 issued by ______________________________ identified by bond number 23 25 ] TANF; [ c. Inventory. An inventory of all property of the Incapacitated Person’s estate at the 18 24 ] Copes; [ _______________, and is in the amount of $_______________ . /// /// /// 26 GUARDIAN’S REPORT AND ACCOUNTING-4 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 For Accounting Period starting ___________________ and ending ______________. 2 Total Assets at Market Value as of the beginning of review period $______________. 3 Income: Social Security: SSI: VA/Railroad/CSA Pension: Retirement Pension: Wages: Interest and Dividends: Other: Total Income: $ $ $ $ $ $ $ $ ____________________ 14 Disbursements: Room and Board: (Rent, Nursing Home) Personal Funds: Entertainment & Travel: Transportation (mileage, bus pass, taxi scrip, etc.) Medical and Dental: Guardian Fees: Attorney Fees: Other: Total Disbursements: $ $ $ $ $ $ $ $ $ ____________________ 15 Adjustments: (Net gain/loss in value of assets over accounting period)$ ____________________ 16 Total Assets: (as of closing date of accounting period) $ ____________________ 17 Explanation: (for any large or unusual expenditures, adjustments, or purchases) __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ _________________________________________________________________________. /// /// /// 4 5 6 7 8 9 10 11 12 13 18 19 20 21 22 23 24 25 26 GUARDIAN’S REPORT AND ACCOUNTING-5 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 Asset List: (For all financial accounts, include the type of account, account number, bank 2 or company name, and branch location. You may use the figures from the last statement 3 received from a bank or company prior to the ending date of the accounting period.) 4 (Please use only last four digits of the account numbers.) With: Type: Account #: 5 Balance/Market Value $ Account #: Type: With: $ 7 Account #: Type: With: $ 8 Other: 6 $ 9 10 11 12 13 14 15 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__. Signature of Guardian Printed Name of Guardian, WSBA/CPG# Address Telephone/Fax Number City, State, Zip Code Email Address 16 17 18 19 20 21 22 23 24 25 26 GUARDIAN’S REPORT AND ACCOUNTING-6 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com