ACCOUNTING SUMMARY FORM #3 FOR PROFESSIONAL GUARDIANS (Estates over $80,000.00 in Liquid Assets and/or Real Estate) 14. Estate Information For Accounting Period starting _____________ and ending ________________. A. Total Assets at Market Value as of the beginning of review period $__________. SET FORTH TOTAL FIGURES FOR ENTIRE ACCOUNTING PERIOD. DO NOT USE MONTHLY FIGURES. Income Received from All Sources (do not include new assets purchased) 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: B. Total Income: #29A3-GUARDIAN’S REPORT, ACCOUNTING, AND PRPOSED BUDGET $_____________ PAGE 7 MODIFIED 9/04 American LegalNet, Inc. www.USCourtForms.com 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 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): $ $ $ $ $ $ $ $ Real Property Expenses: Residence Maintenance & Repair Homeowners/Co-op Dues Property Taxes Mortgage Insurance Other (Specify): $ $ $ $ $ $ #29A3-GUARDIAN’S REPORT, ACCOUNTING, AND PRPOSED BUDGET PAGE 8 MODIFIED 9/04 American LegalNet, Inc. www.USCourtForms.com Investment Property Expenses $ Other Expenses Employment Tax Income Tax Payments Costs Advanced Bank/Service Fees Other (Specify): $ $ $ $ $ C. Total Disbursements $_________ Adjustments to Market Value of Estate Addition of Assets/(Liabilities) Not Previously Reported (Do not use this section for assets purchased) $ $ Deletion or Reduction in Value (Assets)/Liabilities Listed on previous accounting $ $ Gifts Received/(Made) Date of Court Order Authorizing $ $ Net Gains/(Losses) from Sales of Assets $ $ 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) D. Total Adjustments to Market Value of Estate: $ $ $ $ $___________ E. Ending Balance at Market Value, as of __________ $____________ (A + B –C +/- D = E) 15. Balance Sheet for the Guardianship/Trust Estate #29A3-GUARDIAN’S REPORT, ACCOUNTING, AND PRPOSED BUDGET PAGE 9 MODIFIED 9/04 American LegalNet, Inc. www.USCourtForms.com ASSETS Description Market Value on Start of Accounting Date: Market Value at End of Accounting Date: $ $ Accounting: Cost Basis at End of Accounting Date: $ $ $ $ Real Property 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) $ $ $ $ $ $ $ $ $ Personal and Other Property (Household Goods, Vehicles, Burial Plots, Funeral Plans, Life Insurance) $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL ASSETS: $ $ $ $ $ $ $ $ at Cost Basis $ at Market Value $ at Market Value LIABILITIES TOTAL LIABILITIES: 16. NET TOTAL ESTATE #29A3-GUARDIAN’S REPORT, ACCOUNTING, AND PRPOSED BUDGET PAGE 10 MODIFIED 9/04 American LegalNet, Inc. www.USCourtForms.com Supporting Documents: Cancelled checks, (if not available, copies of cancelled checks or copies of 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. The supporting documents must be submitted to the Court Administrator’s 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 Printed Name of Guardian, WSBA/CPG# Address Telephone/Fax Number City, State, Zip Code Email Address #29A3-GUARDIAN’S REPORT, ACCOUNTING, AND PRPOSED BUDGET PAGE 11 MODIFIED 9/04 American LegalNet, Inc. www.USCourtForms.com