Gdn Rpt/Accounting/Prop Budget (ANR12, ANR24, ANR36) - Page 1 of 13 WPF GDN 05.0300 (07/2017) RCW 11.92.040, 043 Superior Court of Washington County of In the Guardianship of: , Incapacitated Person No . Guardian222s Report, Accounting, Proposed Budget 12-Month Report (ANR12) 24-Month Report (ANR24) 36 - Month Report (ANR36) Instructions: This report has 4 sections. All Guardians must complete sections A and D. If you are a Guardian of the Person, you must also complete section B. If you are a Guardian of the Estate, you must also complete section C. (Some courts may allow you to submit a copy of the Social Security representative payee form instead of completing section C, IF the incapacitated person222s estate is no more than $2000 and the only source of income is SSI, SSA [Social Security Retirement], and/or SSD [Social Security Disability].) If you are both a Guardian of the Person and a Guardian of the Estate, you must complete sections A, B, C & D of this document. If you need more room to complete any section, attach additional pages. Scope of Guardianship Full OR Limited 226 Guardianship of the Person Full OR Limited 226 Guardianship of the Estate American LegalNet, Inc. www.FormsWorkFlow.com Gdn Rpt/Accounting/Prop Budget (ANR12, ANR24, ANR36) - Page 2 of 13 WPF GDN 05.0300 (07/2017) RCW 11.92.040, 043 General Information Section A 226 Completed by all Guardians 1. Identity of Guardian, Incapacitated Person, and Standby Guardian Incapacitated Person Guardian Standby Guardian Full Name Mailing Address City & State Zip Code *Telephone *Fax Number Age 2. Date of Appointment and Reporting Period The Guardian was appointed on (date) . The last report of the Guardian was approved by the court on (date) . This report covers the period from through . The closing date for all reports is , and the Guardian is required to file reports within 90 days of that date. The Guardian is to file a report every 12, 24, 36 months. 3. Interested Parties (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.) Name Mailing Address Relationship to Incapacitated Person 4. Interested Governmental Agencies (Check each box that is applicable.) The incapacitated person is a veteran of the United States Military who is receiving or has received veteran222s benefits and the Guardian of the estate manages those veteran222s benefits. Notice must be provided at least 15 days before the hearing to: The Department of Veteran222s Affairs: WAREA Fiduciary Hub, Department of Veteran Affairs, 550 Foothill Drive, P.O. Box 58086, Salt Lake City, UT 84158. (Check www.va.gov to verify the address is current.) (RCW 73.36.020). The incapacitated person is a Medicaid client of the Department of Social and Health Services (DSHS) who (1) pays Guardian222s fees; and (2) is required to contribute to the cost of his or her care in a nursing home or other similar facility. Notice must be provided at least 10 days before the hearing to DSHS. (WAC 388-79-050). American LegalNet, Inc. www.FormsWorkFlow.com Gdn Rpt/Accounting/Prop Budget (ANR12, ANR24, ANR36) - Page 3 of 13 WPF GDN 05.0300 (07/2017) RCW 11.92.040, 043 Other: . 5. Benefits Received The Guardian receives the following monthly benefits on behalf of the Incapacitated Person, in the following amounts: SSDI/SSA: $; Medicaid $; SSI: $; Medicare $; GAU: $; COPES $; VA Pension: $; TANF $; L&I Benefits: $; HUD $; Food Stamps $ ; DDA $. Other 226 Specify: A Trust that reports to the court: the Trustee222s name, address, and court case number are: A Trust that does not report to the court: the Trustee222s name, address: 6. Inventory An inventory of all property of the Incapacitated Person222s estate at the commencement of the Guardianship is or is not on file herein. 7. Bond and Blocked Accounts There is or is not currently a bond in place in the amount of $ (Bond No.: ). The total balance of assets in blocked accounts is $ . The total balance of assets in unblocked accounts is $ . The bond should remain or should be changed to $ . Assets in excess of the bond amount should be restricted (i.e. blocked) and should be subject to a Receipt of Funds into Blocked Financial Account, form WPF GDN 04.0600, on file with the court. 8. Guardian Fees The Guardian is requesting fees and costs in the amount of $ for the period of through . The Guardian has or has not received American LegalNet, Inc. www.FormsWorkFlow.com Gdn Rpt/Accounting/Prop Budget (ANR12, ANR24, ANR36) - Page 4 of 13 WPF GDN 05.0300 (07/2017) RCW 11.92.040, 043 payments in the amount of $ during this accounting period for their services. The Guardian has attached to this report (or has filed with this report) a separate itemized fee declaration that describes in detail: the services rendered, the time period that services were provided, the time required to provide the services, the requested rate of compensation, and the out of pocket costs incurred. The Guardian is requesting that the amount of $ be disbursed from the guardianship assets. During this accounting period the Guardian has performed the following duties: . 9. Attorney Fees The Guardian has retained the services of the Law Offices of , and is requesting that fees and costs in the amount of $ for the time period of through be paid from guardianship assets. Attached in this report (or filed herewith) is a separate itemized fee declaration that describes the legal services provided. 10. Guardian222s Monthly Allowance Pursuant to RCW 11.92.180, the Guardian is requesting a monthly allowance for ongoing: (a) guardian fees and costs and (b) attorney fees and costs for services already performed. The amount of guardian fees and costs and attorney fees and costs for services performed for the previous accounting period totaled $. This is a monthly average of $ . The actual monthly allowance that the guardian received during the previous accounting period was $ . The guardian now requests a monthly allowance of $ . This allowance (paid monthly) would be considered an 223advance224 on the fees and costs billed by the guardian, or its attorney, for services already performed. However, the total fees and costs billed (notwithstanding the allowance payments) should: (a) ultimately be subject to the review and approval of the court and (b) create no presumptions by the court or the guardian regarding the reasonableness, or necessity, of those fees and costs. Said monthly allowance should be made effective as of (date) . 11. Lay Guardian Training Does not apply. The guardian is a certified professional guardian or financial institution. (Name of guardian) successfully completed the required lay guardian training. The certificate of completion is is not on file with the court or attached. The court waived (name of guardian) 222s requirement to complete lay guardian training. American LegalNet, Inc. www.FormsWorkFlow.com Gdn Rpt/Accounting/Prop Budget (ANR12, ANR24, ANR36) - Page 5 of 13 WPF GDN 05.0300 (07/2017) RCW 11.92.040, 043 The guardian or limited guardian was required to complete additional or updated training. (Name of guardian) successfully completed this additional or updated training. The certificate of completion is is not on file with the court or attached. 12. Court Approval The guardian petitions the court for approval of this report. Guardian of the Person Section B 226 to be completed by the Guardian of the Person. 13. Status Report a. Status The Guardian believes that the Incapacitated Person is receiving satisfactory care or the Guardian has the following concerns for which a change is requested:. b. Change in Residence The following changes in residence of the Incapacitated Person occurred during the reporting period: . c. Medical Condition The medical condition of the Incapacitated Person including any changes during the reporting period: . d. Mental Condition The mental condition of the Incapacitated Person including any changes during the reporting period: Note: If there exists a mental health professional report on the status of the Incapacitated Person, you must file it with the court. To protect privacy, it sho