Fill and Sign the Court of Chancery Kent County Location Hours Ampamp Locations Form

In the matter of: , a disabled person or T/U/W IN THE COURT OF CHANCERY OF THE STATE OF DELAWARE Register in Chancery Kent County 38 The Green Dover, DE 19901 302- 735-1930 Register in Chancery New Castle County 500 N. King Street, St. 1551 Wilmington, DE 19801 302- 255-0544 Register in Chancery Sussex County 34 The Circle Georgetown, DE 19947 302- 856-5775 In the Matter of: ) ) Court of Chancery C.M. # , ) a disabled person ) GUARDIAN’S ACCOUNT Accounting Number: [First, Second, Third, or Final Please circle or fill -in the appropriate number Accounti ng Period: to Beginning Date Ending Date Date Guardian was appointed: Guardian’s Information Guardian’s name: Guardian’s complete address: Guardian’s phone number: If applicable: Co-Guardian’s name: Co -Guardian’s complete address: Co -Guardian’s phone number: Disabled Person’s Information Per Chancery Rul e 180(b), the attached status report must also be filed (with the Doctor’s signature). In the matter of: , a disabled person or T/U/W IN THE COURT OF CHANCERY FOR THE STATE OF DELAWARE , C.M.# Disabled Person ANNUAL UPDATE & MEDICAL STATEMENT (GUARDIAN must complete the section below.) I, , was appointed Guardian of Guardian’s name on . Disabled person’s name Date of Final Order for Appointment of Guardianship 1. My current mailing address i s the following: 2. My current telephone number is: 3. Name of Disabled Person: Date of Birth: 4. Disabled Person’s Residence: Type of facility: Disabled Person’s Home Guardian’s Home Group Home Foster Home Nursing Home State Facility Other (specify) Agency providing care (i .e. Easter Seals, Chimes, DDDS, etc): Other agencies involved with the disabled person: If there has been a change in residence since last review, give a reason for the change: 5. Describe the management of the disable person’s financial aff airs: If the guardian(s) do(es) not manage the disabled person’s financial affairs, who does? 6. Have burial arrangements been established for the disabled person? Yes No If so, through what provisions: In the matter of: , a disabled person or T/U/W 7. Describe relationship with family (or interested parties): 8. Any additional information the Guardian desires to share with the Court: 9. Explain why this guardianship should be continued: Date Guardian’s signature Date Co-Guardian’s signature In the matter of: , a disabled person or T/U/W (PHYSICIAN must complete the section below) The attending physician, _______________________________________, last examined Physician’s name ________________________________ on the following date ___________________. Disabled person’s name Describe physical health of the disabled person/diagnosis: ________________________ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ _________________________________________________________________________\ _____ ________________________________________________ Significant changes since last review: _________________________________________ ______________________________________________________________________________ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ______________________________________________________ Hospitalizatio ns/Surgical procedures since last review: ___________________________ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ______________________________________________________________________________ ______________________________________________________ Consequently, there is a continued need for guardianship of the disabled person: Yes No If No, why not? _______ ___________________________________________________ ________________________________________________________________________\ ______ ________________________________________________________________________\ ______ ______________________________________________________________________________ ______________________________________________________ ___________________ ________________________ Date Physician’s signature In the matter of: , a disabled person or T/U/W Additional Information Regarding Accountings (Please see the Court of Chan cery Rules for further information) The Guardian(s) is/are required to file an accounting every year on the anniversary date of their appointment as Guardian (per Chancery Rule 114) . If additional space is required on schedules, please insert sheets of the same size. All items must be listed as separate entries (i.e. Social Security must be listed each month it was received, not as one lump payment). Spreadsheets can be filed as an attachment to any schedule. Please make sure to supply the name, relat ionship and current address of all next-of -kin (interested parties). If they are minors, then the name and address of his or her guardian should be provided. Please keep in mind that anyone listed in the petition as a next -of -kin is to be included on all a ccountings filed (per Chancery Rule 118). The Guardian(s) signature (s) is/are to be notarized on either the C -16- A or C -16- B form (the last two pages of this sample). The Guardian(s) is/are also required to provide cancelled checks, bank statements, re ceipts and any other pertinent information to show how the disabled person’s money was used (per Chancery Rule 120). Once your accounting has been audited by the Register in Chancery Clerk, a bill will be mailed to the guardian(s); the fees are based on C hancery Rule 3(bb). In addition, the guardian(s) will be charged a $10.00 fee for the clerk to electronically file the accounting. Supporting documents (i.e. bank statements, receipts, etc.) are not kept by the Register in Chancery after the accounting h as been reviewed by the Judge (call ed a Master in Chancery Court), so please select one of the following options: As the guardian(s), I wish for all supporting documentation to be - Shredded by the Register in Chancery Clerk Returned to the guardian (If you choose this box, you will be called and given thirty days to pick up the documents or they will be shredded. You may also choose to give the clerk a pre- paid envelope for the items to be returned to you.) Any and al l questions regarding the guardianship accounting p rocess should be directed to the county where the guardianship was established. I have read the accounting instructions. ________________________________ _________________ Guardian Date ________________________________ _________________ Co -Guardian Date In the matter of: , a disabled person or T/U/W SUMMARY SCHEDULE TITLE VALUE A PRINCIPAL ON HAND $ B ADDITIONS TO PRINCIPAL $ C INCOME RECEIVED $ TOTAL: $ D DEDUCTIONS FROM PRINCIPAL $ E INCOME PAID OUT $ TOTAL: $ F PRINCIPAL REMAINING ON HAND $ ***PLEASE NOTE THAT A COPY OF ALL BANK STATEMENTS, RECEIPTS AND INVOICES PAID DURING THE ACCOUNTING PERIOD MUST BE FILED WITH THE ACCOUNTING. In the matter of: , a disabled person or T/U/W SCHEDULE A AMOUNT OF PRINCIPAL ON HAND ON (Date) . This amount should be the same amount of the original principal reported in the inventory if this is a First Accounting or the ending principal of the last account ing . (This schedule includes all bank accounts, real estate owned by ward, household furni shings, automobiles, all miscellaneous furnishings, etc.,) DESCRIPTION OF ASSET VALUE $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ In the matter of: , a disabled person or T/U/W SCHEDULE B ADDITIONS TO PRINCIPAL, WHEN MADE, AND THE SOURCE FROM WHICH THEY WERE OBTAINED. This should include Capital Gain in stock, sale of real estate , etc. Please state: (1) the date of the transaction, (2) the description of the investment and (3) the gain realized. DATE OF TRANSACTION DESCRIPTION OF INVESTMENT GAIN REALIZED $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ In the matter of: , a disabled person or T/U/W SCHEDULE C INCOME RECEIVED, WHEN RECEIVED AND FROM W HAT SOURCE. This schedule should include any and all income received such as social security, pension, alimony, certificate of deposit interest, dividends and interest from stock, interest on savings accounts, income from rental properties, etc. DATE TRANSACTION DESCRIPTION VALUE $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ In the matter of: , a disabled person or T/U/W SCHEDULE D DEDUCTIONS FROM PRINCIPAL, WHEN MADE AND FOR WHAT PURPOSE. This schedule should include actual losses on investments. Examples are capital losses on stocks, and/or losses from sale of pr operty. (If a household article was appraised at $2000.00, but sold for $1,500.00, this would result in a $500.00 loss). DATE TRANSACTION DESCRIPTION VALUE $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ In the matter of: , a disabled person or T/U/W SCHEDULE E INCOME PAID OUT\EXPENSES PAID , TO WHOM, WHEN PAID, AND FOR WHAT PURPOSE. This schedule should include all income paid out for the benefit of the disabled person or T/U/W (also include any and all bank service charges). DATE CHECK # TO WHOM/CREDITOR AND PURPOSE AMOUNT $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ In the matter of: , a disabled person or T/U/W SCHEDULE F PRINCIPAL ON HAND AT THE END OF THE ACCOUNTING PERIOD. This schedule should include the remaining balance in all bank accounts aft er all deductions and additions are made. This schedule should also include any real or personal property of the ward that is still in their possession (which has not been sold). Please include the source and the amount. SOURCE VALUE $ $ $ $ $ $ $ $ $ $ $ $ $ TOTAL: $ In the matter of: , a disabled person or T/U/W LIST OF BENEFICIARIES/INTERESTED PARTIES The following is a list of any and all next- of-kin and any beneficiaries over the age of eighteen in regard to the Guardianship created for the benefit of , a Minor/Disabled Person (if the beneficiary is under the age of eighteen, list the legal custodian). Name of Beneficiary Address of Beneficiary Relationship 1 2 3 4 5 6 7 8 9 10 11 12 In the matter of: , a disabled person or T/U/W NOTE: WAIVER OF NOTICE AND CONSENT Chancery Rule 119 states that all next -of -kin must rece ive notice when the annual accounting is filed. Next -of -kin is generally defined as the disabled person’s spouse, children, parents and/or siblings. Please note that anyone who was listed on the original petition will be considered the next -of -kin. The gua rdian must make every attempt to provide an up- to-date address for all next - of -kin. Should a family member pass away, a copy of a death certificate should be provided to the Court. The waiver of notice can be handled in the following two ways: 1) All next of kin can sign the attached waiver of notice and consent to the accounting. (Please note that signatures will need to be notarized). 2) For any next -of -kin where a consent is not attached, the Chancery Court Clerk will mail a notice to them. Chancery Rule 119 then states that the next -of -kin will have thirty days to come in and view the accounting if they wish. In the matter of: , a disabled person or T/U/W IN THE COURT OF CHANCERY OF THE STATE OF DELAWARE In the Matter of: ) ) C.M. No. , ) ) a disabled person ) WAIVER OF NOTICE AND CONSENT TO THE ACCOUNT OF THE GUARDIAN(S) The undersigned hereby waives Rule 119 of the Court of Chancery of the State of Delaware with regard to Notice of Account. I, , do hereby approve said account and waive notice of filing of the same, having read and examined the account of the Guardian(s). _________________________________ Date (Signature) SWORN AND SUBSCRIBED before m e the date and year aforesaid. _________________________________ Notary Public In the matter of: , a disabled person or T/U/W All accountings EXCEPT Final Guardianship Case # Account IMO COURT OF CHANCERY, REGISTER IN CHANCE RY STATE OF DELAWARE , guardian, duly qualified according to law, deposes and says that the foregoing is just and true to the best of his/her knowledge and belief. Guardian Co-Guardian Sworn to and subscribed before me this _________day of _____________A.D. 20____. ___________________________________ ________________________________\ __ Notary Public Notary Public (Section below to be completed by the Court) I, , do here by certify that I have examined the foregoing account, tried the calculations and additions, compared the vouchers and find the same correct as shown. _________________________________ ________________________________\ ___ Court Clerk Register in Chancery And further, that on the day of A.D. 20 , I did send by mail to the beneficiary(ies) at their add resses shown in the accounting notice that said account had been filed and would remain open for inspection and exception of any interested party for thirty days from said date; and that no exceptions thereto have been filed to the ____ day of ___________________A.D.20_____. ________________________________ _________________________________\ ___ Court Clerk Register in Chancery And now, to- wit, this ____ day of _____________________ A.D.20____, the foregoing account having been examined and neither the guardian/trustee nor any party of interest has requested that the investment of the principal be approved or disapproved, it is therefore orde red by the Court that the remainder of the account be and hereby is approved, without passing upon the manner in which the principal has been or is now invested. _________________________________________ CHANCELLOR/VICE CHANCELLOR/MASTER In the matter of: , a disabled person or T/U/W For Final Accountings Only Guardianship Case # IMO COURT OF CHANCERY, REGISTER IN CHANCERY STATE OF DELAWARE , Guardian, duly qualified according to law, deposes and says that the foregoing account is just and true to the best of his/her knowledge and belief. __________________________________ ____________________________________ Guardian Co-Guardian Sworn to and subscribed before me this ____ day of _______________________ A.D. 20____. __________________________________ ______________________________________ Notary Public Notary Public (Section below to be completed by the Court) I, , do hereby certify that I have examined the foregoing account, tried the calculations and additions, have compared the vouchers and find the same correct as shown. _________________________________ ______________________________________ Court Clerk Register in Chancery And further, that on the ____ day of _________________________, 20____, I did send by mail to the beneficiary(ies) at their addresses shown in the accounting a notice that said account had been filed and would remain open for inspection and exception of any interested party for thirty days from said date; and that no exceptions thereto have been filed to this the ____ day of _____________________, 20____. ________________________________ _____________________________________ Court Clerk Register in Chancery This _____ day of ____________________________, 20____, the foregoing account has been examined and neither the trustee nor any party of interest has requested that the investment of the principal be approved or disapproved; it is therefore ordered by the Court that the remainder of the account be and hereby is approved, without passing upon the manner in which the principal has been or is now invested. Upon the approval of the Petition to Terminate , the fiduciary will be discharge d and the bond cancelled. CHANCELLOR/VICE CHANCELLOR/MASTER