SUPERIOR COURT OF WASHINGTON IN AND FOR SNOHOMISH COUNTY CASE NO. ACCOUNTING OF GUARDIAN AND PROPOSED BUDGET In the Guardianship of: GR 1 08-11 1 year 3 year Other Final ________________________________ an Incapacitated Person. General Instructions (1) This form should be used by all 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 accounting 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 at: http://snohomishcountywa.gov/438/Clerk-Superior-Court-Forms 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: S:\Systems, Technology & Equipment\Web\SC\Current webpage forms\guardianship monitoring program forms\GR1.doc 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: E-Mail: ( ) ( ) S:\Systems, Technology & Equipment\Web\SC\Current webpage forms\guardianship monitoring program forms\GR1.doc Page 2 of 13 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 S:\Systems, Technology & Equipment\Web\SC\Current webpage forms\guardianship monitoring program forms\GR1.doc Page 3 of 13 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. (a) 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 13 of this form) and complete this section. no If you checked this box, proceed to section 6(b) 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 Page 4 and 5 then go directly to Page 12 and sign. 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? (b) Is the ward a beneficiary of a trust. [ ]Yes [ ]No If you have checked "Yes", 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 Trustees Report to this accounting?: yes no If "no", why not? S:\Systems, Technology & Equipment\Web\SC\Current webpage forms\guardianship monitoring program forms\GR1.doc Page 4 of 13 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 on Page 6 or