ACCOUNTING SUMMARY FORM #1 ­ GENERAL PURPOSE FOR NON-PROFESSIONAL GUARDIANS (Estates in excess of $80,000.00 in liquid assets and/or real estate) 14. Estate Information For Accounting Period starting ___________________ and ending___________________. Value at Beginning Value at End of of Accounting: Accounting: Date: __________ Date: __________ Description and last four digits of account # Real Estate Difference Bank and Investment Accounts (include financial institution and last four digits of account # only) Money Owed TO the Incapacitated Person (Mortgages, Contracts, Promissory Notes Payable to the Incapacitated Person) Furniture, Vehicles, Boats, and Other Personal Property 15. Total Value of Assets GUARDIAN'S REPORT, ACCOUNTING AND PROPOSED BUDGET - Page 6 SPO GDN 02.0291 (12/2015) American LegalNet, Inc. www.FormsWorkFlow.com Liabilities (List all debts or obligations of the Incapacitated Person and the Estate) 16. Total of Liabilities 17. Net Totals (Item 15 minus Item 16) SET FORTH TOTAL FIGURES FOR ENTIRE ACCOUNTING PERIOD. DO NOT USE MONTHLY FIGURES. 18. Income Received From All Sources During the Reporting Period a. b. c. d. e. f. g. Wages Social Security Retirement Benefits Disability Health Insurance Benefits Other Monthly Income Gain on Sale of Asset: Asset: Asset: h. Interest on Certificate(s) of Deposit i. Income on Mutual Funds j. Savings Account Interest k. Money Market/Checking Account Income l. From Trust or Spousal Maintenance m. Adjustment for Increase in Value of: n. Adjustment for Increase in Value of: o. Other: 19. Total Income Current Monthly Benefit $ $ $ $ $ $ $ Total Received $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ GUARDIAN'S REPORT, ACCOUNTING AND PROPOSED BUDGET - Page 7 SPO GDN 02.0291 (12/2015) American LegalNet, Inc. www.FormsWorkFlow.com 20. Disbursements and Outgoing Payments Personal Living Expenses a. Housing (Rent/Mortgage) at: b. Heat/Lighting/Water/Sewer/Cable/Telephone c. Household Maintenance d. Food and Household Supplies e. Clothing f. Personal Care and Services (Other than Medical Attendants) g. Insurance for: h. Allowance or Money Given Directly to Incapacitated Person i. Auto and Transportation j. Travel k. Other: Healthcare Expenses l. Health Insurance Premium m. Doctor Fees n. Hospital and Health Care Providers o. Prescription and Pharmacy p. Medical Transportation q. Visiting Nurse/Companion Services r. Other: Professional Fees s. Guardian Fees t. Attorney Fees for Guardian u. Attorney Fees for Petitioner v. Guardian ad Litem Fees and Costs w. Trustee Fees x. Bond Premium y. In-Home Services z. Accounting Fees aa. Other: Other Expenses bb. Subscriptions cc. Bank Charges dd. Federal Income Tax ee. Gifts ff. Adjustments for Decrease in Value of: gg. Adjustments for Decrease in Value of: hh. Other: $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 21. Total Disbursements Outgoing From Incapacitated SPO GDN 02.0291 (12/2015) GUARDIAN'S REPORT, ACCOUNTING AND PROPOSED BUDGET - Page 8 American LegalNet, Inc. www.FormsWorkFlow.com Person's Estate 22. Net Total of Income and Disbursements (Item 19 minus Item 21) 23. .Total Assets (as of closing date of accounting period: $ $ Supporting Documents: Cancelled checks, (if not available, copies or images of cancelled checks along with check registers), monthly bank statements, brokerage statements, and an itemized list of all transactions must be included for each account for the reporting period to support the declarations made in this report. Time logs/invoices must be provided for fees requested. The supporting documents must be submitted to the Guardianship Monitoring Program Office with a copy of this report. Do not file the supporting documentation in the court legal file. 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________________, 20_____. _________________________________________ Signature of Guardian ____________________________ Address ____________________________ *Telephone/Fax Number Printed Name of Guardian, WSBA/CPG# _____________________________________ City, State, Zip Code _____________________________________ Email Address *Under GR 22 (b) (6), parties' personal telephone number(s) are confidential information. If you do not want your personal phone number(s) on this public form, complete form #S2Sealed Confidential Information and file in the confidential file. GUARDIAN'S REPORT, ACCOUNTING AND PROPOSED BUDGET - Page 9 SPO GDN 02.0291 (12/2015) American LegalNet, Inc. www.FormsWorkFlow.com