(Copy Receipt) (Clerk’s Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE CASE NO. __________________________ In the Guardianship of: GUARDIANSHIP INVENTORY RCW 11.92.040(1) _____________________________________ (INV) The Full Limited Guardian of the Estate, being first duly sworn, states that the following is a true and correct inventory of the assets and liabilities of the Incapacitated Person as of the date of the Order Appointing the Guardian. A. ASSETS 1. Real Estate: including the address of the property and its tax assessed value: _________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. Financial Accounts: including the name, address, and phone of the financial institution, type of account, last four digits of account number, and balance in each account (for example, savings, checking, money markets, certificates of deposit, retirement accounts, and all investment accounts): #21-GUARDIANSHIP INVENTORY PAGE 1 OF 3 Revised 3/07 American LegalNet, Inc. www.FormsWorkflow.com Name of Financial Institution Account Type Acct. # Balance (last 4 digits only) As of Date Address & Phone Address & Phone 3. Stocks, Bonds, and other Securities (not held in an account listed above). Name of Financial Account Acct. # Balance (last 4 digits only) Institution Type As of Date Address & Phone Address & Phone 4. Personal Property Summary: Household Furnishings $ Automobile/Boats $ Other (including items on attached list) $ (Attach itemized list of only those items valued at $1,000 or more.) TOTAL ASSETS $__________________ B. Income Description Wages Supplemental Security Income (SSI) Social Security Retirement Veteran’s Benefits Retirement Pension Dividends and Interest Other: Disability Disability Per Month $ $ $ $ $ $ $ TOTAL INCOME $__________________ #21-GUARDIANSHIP INVENTORY PAGE 2 OF 3 Revised 3/07 American LegalNet, Inc. www.FormsWorkflow.com C. LIABILITIES/DEBTS Mortgages and Liens: name and address of each mortgage or lien holder and the amount owing the property encumbered and the amount due monthly: _________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Installment Loans and Notes: name and address of each loan holder, the amount owing and the amount due monthly: ___________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Credit Cards: name and address of each credit card company and the outstanding balance owing on each and the amount due monthly: _______________________________________________ ______________________________________________________________________________ TOTAL LIABILITIES/DEBTS $_____________ D. SUPPLEMENTAL INFORMATION (OPTIONAL) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 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 above are true and correct. SIGNED at __________________, Washington this ______ day of ________________, 20 ____ Signature of Guardian Printed Name of Guardian, WSBA/CPG # Address City, State, Zip Code *Telephone/Fax Number 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. #21-GUARDIANSHIP INVENTORY PAGE 3 OF 3 Revised 3/07 American LegalNet, Inc. www.FormsWorkflow.com