GN-3500, 05/18 Account of Guardian/Conservator 24724754.19(5), 54.62, 54.66 and 54.76, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 1 of 3 STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name Date of Birth Amended Account of Guardian/Conservator Annual Interim Final Case No. UNDER OATH, I STATE: I am the Guardian or Conservator of the above named ward or individual. I certify that this is an accurate account of the administration of the guardianship or conservatorship for the period from to . Line Summary Explanation Total 1. Beginning Balance. Do not change this amount. (Inventory net value or ending balance from prior account.) $ 2. Total of newly discovered assets and income received during this period. (Add) (Attach Schedule A - Assets and Income Received .) $ 3. Subtotal $ 4. Total disbursements, distributions and losses incurred. (Subtract) (List details in Schedule B Disbursements, Distributions and Realized Capital Losses . ) $ 5. Ending Balance (Total Assets on Hand) at end of accounting period. (List details in Schedule C Assets on Hand.) Beginning Balance for next Account $ Status of Surety on Bond The status of the surety upon the guardian or has not changed. has changed. Explain: Guardian/Conservator Co - Guardian/Conservator Name Printed or Typed Telephone Number Name Printed or Typed Telephone Number Address Address State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: State of County of Subscribed and sworn to before me on Notary Public/Court Official Name Printed or Typed My commission/term expires: American LegalNet, Inc. www.FormsWorkFlow.com GN-3500, 05/18 Account of Guardian/Conservator 24724754.19(5), 54.62, 54.66 and 54.76, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 2 of 3 (If the space given is insufficient for any item, attach additional sheets.) Schedule A Assets and Income Received See attached Description (Example: Social security, pensions, interest, dividends, rental or other income, realized capital gains from assets sol d for more than inventory value or purchase price if acquired after the initial inventory , assets discovered after filing initial inventory .) Amount Enter Total on Page 1 Summary Explanation, Line 2. $ Schedule B Disbursements, Distributions and Realized Capital Losses See attached Itemize Disbursements , Distributions and Realized Capital Losses (Example: Costs of care of the ward /individual ; payments made for the benefit of the war d/individual ; assets sold for less than inventory value or purchase price if acquired after the initial inventory.) Amount Enter Total on Page 1 Summary Explanation, Line 4. $ American LegalNet, Inc. www.FormsWorkFlow.com GN-3500, 05/18 Account of Guardian/Conservator 24724754.19(5), 54.62, 54.66 and 54.76, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 3 of 3 Schedule C Assets on Hand (at end of accounting period) See attached Cash, Checking Accounts, Savings Accounts, Certificates of Deposit [Include Institution Name ( s) and Account Type ] Amount (List balance at end of accounting period .) Investments Amount (List inventory value, or purchase price if acquired after the initial inventory.) Real Estate /Property (Including Encumbrances) (Description of property including digital property as defined under 247 711.03(10), Wis. Stats., legal description of real estate, and related encumbrances, liens or other charges against each item .) Amount (List inventory value, or purchase price if acquired after the initial inventory.) Other Assets (Including Burial Trusts) Amount (List inventory value, or purchase price if acquired after the initial inventory.) Enter Grand Total on Page 1 Summary Explanation, Line 5. $ For Authorized Persons Only Display of Assets and Examination of Accounts : I am not the guardian or conservator. I am authorized by the court to examine assets. I have examined all securities, depository accounts, and other investments, and such assets correspond with the account, except as indicated. Authorized Signature (Not guardian/conservator) Name Printed or Typed Title Date American LegalNet, Inc. www.FormsWorkFlow.com