Fill and Sign the Account Guardian Conservator 497431016 Form

STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY For Official Use IN THE MATTER OF       Amended Account of Guardian/Conservator Annual Interim Final       Date of Birth Case No.       I am the Guardian or Conservator of the above named ward or conservatee. 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 conservator’s bond: has not changed. has changed. Explain:       Signature of Guardian/Conservator Signature of Co-Guardian/Conservator Name Printed or Typed       Telephone Number       Name Printed or Typed       Telephone Number       Address       Address       Subscribed and sworn to before me on       Notary Public/Court Official My commission expires:       Subscribed and sworn to before me on       Notary Public/Court Official My commission expires:       Name of Attorney       Telephone Number       Bar Number       Address       GN-3500, 10/06 Account of Guardian/Conservator § §54.19(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 GN-3500 Account of Guardian/Conservator Page 2 of 4 Case No. (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 sold for more than inventory value or purchase price if acquired after the initial inventory, assets discovered after filing initial inventory.) Amount             Total: (Enter in Summary on Line 2 on page 1.) $       GN-3500, 10/06 Account of Guardian/Conservator § §54.19(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 4 GN-3500 Account of Guardian/Conservator Page 3 of 4 Case No. Schedule B – Disbursements, Distributions and Realized Capital Losses See attached. Itemize Disbursements, Distributions and Realized Capital Losses (Example: Costs of care of the individual; payments made for the benefit of the individual; assets sold for less than inventory value or purchase price if acquired after the initial inventory.) Amount             Total: (Enter in Summary on Line 4 on page 1.) $       GN-3500, 10/06 Account of Guardian/Conservator § §54.19(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 4 GN-3500 Account of Guardian/Conservator Page 4 of 4 Case No. Schedule C – Assets on Hand (at end of accounting period) See attached. Cash, Checking Accounts, Savings Accounts, Certificates of Deposit (Including Names and Account Numbers) Amount (List balance at end of accounting period .)             Investments Amount (List inventory value, or purchase price if acquired after the initial inventory.)             Real Estate (Including Encumbrances) 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.)             Grand Total: (Enter in Summary on Line 5 on page 1.) $       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 GN-3500, 10/06 Account of Guardian/Conservator § §54.19(5), 54.62, 54.66 and 54.76, Wisconsin Statutes This form shall not be modified. It may be supplemented with additional material. Page 4 of 4