Fill and Sign the Adult Conservatorship Inventory and Asset Management Plan Form

GEORGIA PROBATE COURT STANDARD FORM Effective 7/072 GPCSF 58 CompleteAdult Conservatorship Inventory and Asset Management Plan INSTRUCTIONS I.Specific Instructions1.This form is to be used pursuant to O.C.G.A. §29-5-30.II.General InstructionsGeneral instructions applicable to all Georgia probate court standard forms are available in each probate court. GEORGIA PROBATE COURT STANDARD FORM Effective 7/072 GPCSF 58 Complete PROBATE COURT OF COUNTY STATE OF GEORGIA ADULT CONSERVATORSHIP INVENTORY AND ASSET MANAGEMENT PLAN WARD: ESTATE NO. ___________________ CONSERVATOR(S): _________________________________________________________________REAL PROPERTY(Indicate if property is jointly owned and with whom) Description CountyState Approximate equityParcel 1 $ __________________Parcel 2 $ __________________Parcel 3 $ __________________INCOME FROM ALL SOURCES Yearly Total Social Security per year $__________________SSI (Supplemental Security Income) per year $ __________________ Retirement benefits per year (payor): $__________________ Retirement benefits per year (payor): $__________________VA benefits per year$__________________Other income per year, including, e.g., alimony, annuity, or trust distributions (payor): $__________________Interest, dividend, or investment income $__________________ YEARLY TOTAL OF ALL INCOME $__________________ If the Ward is a beneficiary of a Trust, please show the name of the Trust, the Trustee, his/her address,telephone number, and attach an outline showing when and how payments are required to be made under the Trust and the criteria for payment: _____________________________________________________ _____________________________________________________________________________________ GEORGIA PROBATE COURT STANDARD FORM Effective 7/072 GPCSF 58 Complete- 2 -PERSONAL AND INTANGIBLE PROPERTY(Indicate if property is jointly owned and with whom)Approximate Current Value1. Checking/Savings/Money Market/Certificates of Deposit/Liquid Accounts: Bank/Financial Institution/Broker Acct. No.Joint Owner (if any) $__________________ $__________________ $__________________ $__________________ 2. Stocks/Bonds/Investments (including retirement and profit-sharing accounts): a. held by brokers: Brokerage Firm or InstitutionAcct. No.Joint Owner (if any) $__________________ $__________________ $__________________ $__________________ $__________________ b. privately held: Company/IssuerNo. of SharesJoint Owner (if any) $__________________ $__________________ 3. Automobiles: Year/Make/ModelV.I.N.Joint owner (if any) $__________________ $__________________ 4. Other assets of significant value: DescriptionJoint owner (if any) $__________________ $__________________ $__________________ TOTAL VALUE OF PERSONAL AND INTANGIBLE PROPERTY $__________________ GEORGIA PROBATE COURT STANDARD FORM Effective 7/072 GPCSF 58 Complete- 3 -DEBTS AND OTHER LIABILITIESThe ward owes the following debts/liabilities:1. Secured debts: Obligor/Payee CollateralSolely/Jointly Owed Approx. Current Balance $___________________ $___________________2. Unsecured debts: Obligor/PayeeAcct. No.Solely/Jointly Owed Approx. Current Balance $___________________ $___________________ TOTAL DEBTS AND OTHER LIABILITIES OF WARD$___________________ AVERAGE MONTHLY LIABILITIES AND EXPENSES Household: Care Facility/Rent/Mortgage payments:$_____________________Property taxes/Insurance$_____________________Utilities/Lawn Care/Pest Control$_____________________Miscellaneous household, food$_____________________Total credit account and other debt payments$_____________________Other (specify) $_____________________ Automotive/Transportation Fuel and Repairs$_____________________Tags and license fees, Insurance$_____________________Bus/train/taxi fares$_____________________ Minors or Other Dependents of the Ward Child Care $_____________________School Tuition/Supplies/Expenses/Lunches $_____________________Clothing/Diapers /Grooming/Hygiene$_____________________Medical/Dental/Prescription$_____________________Entertainment/Activities$_____________________ Other Insurance Health/Life/Disability$_____________________Other (specify)$_____________________ GEORGIA PROBATE COURT STANDARD FORM Effective 7/072 GPCSF 58 Complete- 4 -Ward’s Other Expenses Laundry/Clothing/grooming/hygiene$ Medical/Dental/Prescriptions/medications$_____________________Entertainment/Vacations/Subscriptions/Dues$_____________________Personal Caretakers/cleaning personnel$_____________________Other (specify)$_____________________ Total Expenses $_____________________ Is the ward behind in any debt payments? (yes) (no)If yes, payee and amount: _______________________________________________________________________________________________________________________________________________________ The following extraordinary purchases are anticipated next year: ________________________________________________________________________________________________________________________ SUMMARY 1. Average Monthly Income $_____________________2. Average Monthly Expenses ASSET MANAGEMENT PLAN Please describe how you plan to manage the ward’s assets, including details regarding sale, refinancing, reallocation, investments, or other actions, if any: ____________________________________ ______________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________ (initial:) a. Therefore, based upon the expenses shown above, the Conservator(s) hereby request(s) leave to disburse from the ward’s estate the sum of $ per month for the support, care, education, health, and welfare of the ward and those persons who are entitled to be supported by the Ward. b.Therefore, based on the income of the Ward as shown above, the Conservator(s) hereby request(s) leave to disburse the ward’s income as estimated above for the support of the ward and those persons who are entitled to be supported by the Ward. c.Therefore, based on known one-time expenses, the Conservator(s) hereby request(s) leave to disburse from the Ward’s estate $ one time in the reporting year for the following purpose: ________________________________________________ __________________________________________________________________________________________________________________________________________________ GEORGIA PROBATE COURT STANDARD FORM Effective 7/072 GPCSF 58 Complete- 5 - AFFIDAVIT I/We, , Conservator(s) of the above Ward, do swear that the foregoing Inventory and Asset Management Plan contains a just, true, and complete inventory and budget of all property belonging to said ward within my/our possession, control, or knowledge. This Inventory and Asset Management Plan has been provided to the Guardian of the ward, if any, by first class mail. Sworn to and subscribed beforeme this day of , 20 . ________________________________________ Conservator ________________________________________NOTARY/CLERK OF PROBATE COURT Printed NameMy Commission Expires__________________---------------------------------------------------------------------------------------------------------------------------Sworn to and subscribed beforeme this day of , 20 . ________________________________________ Co-Conservator, if any ________________________________________NOTARY/CLERK OF PROBATE COURT Printed NameMy Commission Expires____________________ Effective 7/07-6-2 GPCSF 58 Complete IN THE PROBATE COURT OF COUNTY STATE OF GEORGIA IN RE: )ESTATE NO. _______________________ ) , )ASSET MANAGEMENT PLANWARD ) ) ,)CONSERVATOR(S)) ORDER The Conservator(s) having filed an Asset Management Plan for the above estate, it is herebyORDERED that the Conservator(s) is/are authorized to disburse from the Ward’s estate: (initial applicable) a. the sum of $ per month for the support of the Ward and his/her dependents. b.the income generated from the corpus of the Ward’s estate for the benefit of the Ward and those persons who are entitled to be supported by the Ward. c.the sum of $ one time during the reporting period for the support of the Ward and those persons who are entitled to be supported by the Ward. IT IS FURTHER ORDERED that said Conservator(s) shall show in the annual return how such funds actually were spent. SO ORDERED this day of , 20 . ________________________________________Probate Judge