SUPERIOR COURT OF WASHINGTON IN AND FOR SNOHOMISH COUNTY CASE NO. ACCOUNTING OF GUARDIAN GR 1 10-07 In the Guardianship of: 1 year 3 year Other Final an Incapacitated Person General Instructions (1) This form is to be used by all non-professional Guardians of estates. For larger more complex estates it may be necessary to attach more detailed schedules. (2) The accounting period starts with the date of your appointment as guardian or the date of the end of the term covered in the last accounting filed, and it ends on the date you indicate below. (3) The length of the account period is one year unless otherwise ordered by the court and the report is due within 90 days thereafter. If this report is past due, you may report for the period ending up to the date of the report and place that date in the blank below, which will then be the starting date for the next accounting period. (4) When the term “guardian” is used, it also covers any co-guardian(s). (5) If a fee for acting as guardian, attorney, or accountant is to be requested, a separate request for court approval thereof must be made. (6) If this is a FINAL accounting, please attach a Final Accounting Supplement (forms available at Guardianship Monitoring Program 425-388-3284 or on the Web) The undersigned Guardian(s) of the estate of the above named incapacitated person (“I.P.”) hereby certify that the attached hereto is a true and correct statement of the receipts, assets, liabilities, and disbursements of the Guardian(s) as follows: Page 1 of 12 American LegalNet, Inc. www.FormsWorkflow.com 1. Accounting Period to be covered in this report (from beginning to ending dates): Check here if the reporting period previously ordered in this case is other than 12 months and, if so, what period: months. Beginning Date of the period covered by this accounting: Check here if this is your first accounting and enter the date of your appointment as guardian: Date (mm/dd/yyyy): Check here if you have previously submitted an accounting and enter the last date covered by the immediately preceding accounting: Date (mm/dd/yyyy): Ending Date of the period covered by this accounting [See general instructions, above, under (3)]: If this is a FINAL accounting, use the date of this report. Date (mm/dd/yyyy): 2. Guardianship Functions: Check here if you are also guardian of the person. If so, a separate status report on the person should be submitted. Check here if you are a “limited” guardian. If so, state your functions as you understand them: 3. Contact Information for Incapacitated Person, Guardian and Standby Guardian: Incapacitated Person: Full Name: Address: City, State, Zip: Phone: ( ) ( ) Guardian: Full Name: Address: City, State, Zip: Phone: Page 2 of 12 American LegalNet, Inc. www.FormsWorkflow.com Standby Guardian: Full Name: Address: City, State, Zip: ( Phone: 4. Interested Parties: ) Instruction: List each person who has filed a Request for Special Notice of Proceedings and those whom the Court has designated to receive copies of reports (See the order appointing Guardian). A copy of this report should be mailed to each. Full Name: Address: City, State, Zip: Relationship to Incapacitated Person: Full Name: Address: City, State, Zip: Relationship to Incapacitated Person: Full Name: Address: City, State, Zip: Relationship to Incapacitated Person: 5. Benefits Received by anyone for the ward: SSDI/SSA SSI Medicaid Medicare Copes TANF HUD Food Stamps GAU Public Assistance VA CSA Other-Specify Page 3 of 12 American LegalNet, Inc. www.FormsWorkflow.com 6. Persons or Agencies, other than the Guardian, receiving, holding managing, or disbursing income benefits, or assets of the ward, such as representative payees and trustees. Does any person or agency other than the Guardian receive, hold, manage or disburse any income, benefits, or assets (including assets in trust) of the incapacitated person? Yes If you checked this box, go to and read Addendum “A” (Page 12 of this form) and complete this section. No If you checked this box, proceed to section 7 and the remaining sections. If you checked the “yes” box above, indicate below whether you, as Guardian, receive, hold, manage, or disburse some or none of the income, benefits, assets or disbursements for the incapacitated person. some If you checked this box, complete this section 6 and/also complete the remaining sections as to the income, assets, etc. which you dealt with as Guardian. none If you checked this box, complete 6 and skip sections 7 through 12 and sign on page 11. For Guardians marking “yes” above furnish the following information regarding the other persons/agencies receiving, holding, managing and/or disbursing income, benefits and or assets of the incapacitated person other than as trustee. 1. Name of Agency or other: 2. Address: City, State, Zip: 3. Contact person: 4. Telephone: ( ) 5. What benefits or other funds are being received or managed by them for the ward: 6. Have you attached a copy of a current report from the agency/person to this accounting?: Yes No If "no", why not? Check here if the ward is a beneficiary of a trust. If you have checked this box, please furnish the following concerning the trust and trustee: 1. Trustee: 2. Address: City, State, Zip: 3. Contact person: 4. Telephone: ( ) 5. Has a copy of the trust been filed in this guardianship proceeding?: Yes No If no, please attach a copy to this report. 6. Have you attached a copy of a current report from the agency/person to this accounting?: Yes No If "no", why not? Page 4 of 12 American LegalNet, Inc. www.FormsWorkflow.com 7. Employment Income of Incapacitated Person. Has he/she been employed for compensation during the accounting period?: No Yes If “yes”, complete the following: Nature of Employment: Basis of compensation and total net income for accounting period: What portion of the compensation do you receive and/or manage as guardian: (should be reported in Section 9, below): How is the other portion received, managed, etc.: ***ATTENTION*** Please review the following Page #6 carefully to determine if it describes your particular accounting needs Page 5 of 12 American LegalNet, Inc. www.FormsWorkflow.com 1.IF the guardianship Assets consist of Personal Effects, such as clothing and used furniture, etc.,( which have a Fair Market value of $3,000 or less) 2.AND, the only other asset is Some Form of Cash, (in Banks, etc.) 3.AND, if average monthly income is less than $1,200 per month, 4.THEN, you may complete this page and proceed to the final page (p. 11) for signature. 5.OTHERWISE, skip this page and complete all of the categories on pages 7 thru 11 of this accounting. In this section account for Monetary Assets held for the benefit of the Incapacitated Person by the Guardian or Designated Payee plus Cash/Check Receipts less cash expenditures. Round all amounts to the nearest dollar. Bank or Other Last 4 Digits Beginning Balance of Account Date: / / Number $ Ending Balance Date: / / $ $ $ $ $ $ Totals $ $ $ * Cash/Check Income: For the period from: / List Sources: Social Security, SSI, Employment, Etc / to Total Cash/Check Income Cash/Check Expenditures: For the period from: / List Expenses: Rent, Food, Medical, Miscellaneous, Etc. / / Amount to / Amount / $ / Total Cash/Check Expenditures $ *Note: The beginning Balance plus the total Income minus the total expenditures should equal the Ending Balance in Bank or Other above. Page 6 of 12 American LegalNet, Inc. www.FormsWorkflow.com Instructions for sections 8, 9, and 10: You need not list the assets held, income received and/or disbursements made by any facility, trustee, etc listed by you in section 6 if you have attached copies of their reports. 8. Assets of the Guardianship: Beginning balance or values from Inventory or end of last accounting period, ending balances as of last day of present accounting period). Instructions - In section 8 through 10, attach schedules where additional space is requires. Category #A Ending Balance As of Date (mm/dd/yyyy): $ $ $ $ $ $ $ $ $ $ Beginning Balance As of Date (mm/dd/yyyy): Ending Balance As of Date (mm/dd/yyyy): $ $ $ $ $ $ $ $ $ Bank, Branch, Account Number (Last 4 digits only) Beginning Balance As of Date (mm/dd/yyyy): $ TOTAL Category #B Bank, Branch, Account Number (Last 4 digits only) TOTAL Page 7 of 12 American LegalNet, Inc. www.FormsWorkflow.com Category #C Ending Balance As of Date (mm/dd/yyyy): $ $ $ $ $ $ $ $ $ Bank, Branch, Account Number (Last 4 digits only) Beginning Balance As of Date (mm/dd/yyyy): $ TOTAL Summary of Assets Beginning Balance As of Date (mm/dd/yyyy): Category: Ending Balance As of Date (mm/dd/yyyy): $ $ $ $ $ $ $ #A Bank Accounts/CD #B Miscellaneous personal property #C Other Assets $ TOTAL 9. Income of Guardianship Estate: Per Month Currency Specify source, such as social security, interest, rent, sale of property, pensions, etc., and employment income, if applicable (see Sec. 6) Total for Accounting Period $ $ $ $ $ $ $ $ $ $ TOTAL Page 8 of 12 American LegalNet, Inc. www.FormsWorkflow.com 10. Expenditures/Disbursements from Guardianship Estate: Instruction: If any amount of the below disbursements are made to or for the benefit of the Guardian(s) or the household thereof, such as for room/board, rent, utilities, transportation, personal care, etc., check the box to the left of the applicable disbursement. Nature of expenditure/disbursement, such as care facility, room/board, medical, personal allowance, clothing, etc. (Describe below. See above instruction for checkbox) Per Month (if applicable) Total for Accounting Period $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL $ $ $ $ * 11. Liabilities of Guardianship Estate: Instruction: This item refers to obligations such as loans, liens, judgments and past due bills or claims, but not current obligations for normal living expenses. Page 9 of 12 American LegalNet, Inc. www.FormsWorkflow.com Per Month (if applicable) Obligations (Describe) Total for Accounting Period $ $ $ $ $ $ $ $ TOTAL $ $ 12. Summary: Instruction: As indicated, insert the figures from Sections 8, 9, and 10. If indebtedness is listed in section 11, call the Guardianship Monitoring Program(see below) for assistance. (a) (b) (c) (d) (e) Beginning summary asset value (Sec. 8)---------------------------Income total for account period (Sec. 9)---------------------------Add lines (a) and (b)--------------------------------------------------Disbursement total for account period (Sec. 10)------------------Subtract line (d) from line (c)---------------------------------------- $ $ $ $ $ * *This figure [line (e)] should roughly approximate the ending balance of assets shown in Sec. 8, which is $ If it does not, it may be the result of a change in the market value of non-cash assets. If you have an explanation, check the box and attach your written explanation hereto. You may call the Guardianship Monitoring Program for assistance at (425) 388-3284, Room C-102 at the Snohomish County Courthouse. Page 10 of 12 American LegalNet, Inc. www.FormsWorkflow.com 13. Guardians' dealings with the incapacitated person's property and /or finances.. Have you (the Guardian) used the incapacitated person’s property, had financial dealings with the ward or: obtained any benefit from the ward during the period covered by this report?: No Yes If “yes” please explain. I/We declare under penalty of perjury as defined by the laws of the State of Washington that the foregoing is true and correct. Signed at , Washington Dated (mm/dd/yyyy): GUARDIAN: (Signature) GUARDIAN: (Signature) NOTE GUARDIANS SHOULD MAKE AND RETAIN A COPY OF THIS FORM WHEN COMPLETED SO THAT FUTURE REPORTS WILL BE CONSISTENT - PARTICULARLY AS TO BEGINNING AND ENDING DATES AND BALANCES Page 11 of 12 American LegalNet, Inc. www.FormsWorkflow.com ADDENDUM “A” TO GUARDIAN’S ACCOUNTING FORM ----------------- SPECIAL INSTRUCTIONS FOR GUARDIANS OF ESTATES IN WHICH PART OR ALL ASSETS, INCOME, AND/OR EXPENSES, ETC., ARE RECEIVED, HANDLED AND/OR DISBURSED BY A PERSON OR AGENCY OTHER THAN THE GUARDIAN In many guardianships some person or agency other than the Guardian is the payee of Social Security, VA or other benefits received for the benefit of the Ward, and/or controls the disbursement of the same, and/or controls assets of the Ward or if the Ward is beneficiary of a Trust. Such other persons or agencies typically are a residential care facility or service agency or a Trustee of a Trust in which the Ward is a beneficiary. If such is the case in your Guardianship, please read carefully and provide the information requested in section 6 of the accounting. It is the responsibility of the Guardian to obtain from such other person, agency or trustee an accounting for the income received, disbursements made and assets possessed or controlled on behalf of the Ward by such person, agency or trustee. The accounting should, if possible, cover the same period of time for which you, as Guardian, are required to report to the Court. You should attach such reports to this Guardian’s accounting form. In many cases a copy of the annual payee reports to Social Security and/or the VA, and in the case of Medicaid or Copes beneficiaries, a copy of the current DSHS Entitlement letter or Eligibility Review form will suffice. Page 12 of 12 American LegalNet, Inc. www.FormsWorkflow.com