Fill and Sign the Fillable Online 11 Form 5 Final Report of Conservator Fax Email

Rule 7.11 — Form 5: Final Repor t of Conservator  If filing electronically, you must provide any protected information in full on form 6, according to Division VI of Chapter 16 of the Iowa Court Rules.  If filing in paper, you may use form 6 to provide any protected information in full. In the Iowa District Court for County In the Matter of the Conservatorship of: Full name: first, middle, last If the Ward is a minor, use initials only Ward. Probate no. Final Report of Conservator 1. This Final Report is for the period from : Use ending date of last accounting when applicable / / to / / Month Day Year Month Day Year 2. Total cash on hand at close of the last accounting: $ . 3. Total sum of funds received during this report period: $ . Include as attachment “A” an itemization showing date received, source of funds, and amount. 4. Total sum of disbursements made during this report period: $ . Include as attachment “B” an itemization showing date, who was paid, and amount paid for item or service. 5. Balance of cash on hand at the close of this report period: $ . 6. Other assets of the Ward at the close of this Final R eport. Include a listing of assets held and the value or remaining balances as attachment "C." If assets remained the same from the last report, a copy of the last listing may be used. 7. Were c hanges made in inves tment during this report period?  Yes  No Include as attachment “D” an itemized list of changes when applicable. 8. The total value of assets of the Ward at the close of this report period : $ . 9. Termination: Include as attachment “E” a statement of reasons for termination. Check one A.  The court on the day of , 20 , ordered termination. B.  Termination is concurrently sought with approval of final report. 10. On termination, funds and assets of this conservatorship will be distributed, if any, to the following: Full name: first, middle, last Relationship to Ward 11. Has n otice of hearing on Final Report been waived?  Yes  No If waived, attach copy of waiver. 12. Amount of Conservator ’s bond: $ . Surety is: . Company providing bond Order approving final report and termination should discharge surety and release bond. May 2014 Rule 7.11 — Form 5 Page 1 of 2 Rule 7.11 — Form 5: Final Report of Conservator , Continued 13. Guardian Check one A.  The Conservator is also the Guardian and has filed a Final Report of Guardian on , 20 . Month Day Year B.  The name of the Ward’s Guardian is: Full Name: first, middle, last C.  The Ward has no Guard ian. If you check C, you must fill in the following information. (1) The residence and physical location of Ward: Street Address City State ZIP code (2) General physical and mental condition of Ward: 14. Other information relating to affairs of the conservatorship: If conservatorship has special circumstances that do not adapt to this form, include attachment “F,” setting out special circumstances in detail. 15. Have final court costs been paid?  Yes  No 16. Fees for Conservator are:  hereby applied for  waived. Attach Affidavit per Iowa Code section 633.202. 17. Fees for Conservator 's attorney: Check one A.  should be set by the court. B.  are not requested. C.  are waived or not applicable. Attach Affidavit per Iowa Code section 633.202, if fees requested. 18. Receipt(s) of the distributee(s) for the funds and assets of the conservatorship: Check one A.  are attached. B.  will be attached to supplemental report after court approves Final Report. 19. Oath and Signature I, , have read this Final Report, and I certify under penalty Print Conservator’s name of perjury and pursuant to the laws of the State of Iowa that the information I have provided in this Final Report is true and correct. , 20 Month Day Year Conservator’s signature* Mailing address City State ZIP code ( ) Phone number Email address Additional email address, if applicable * Whether filing electronically or in paper, you must handwrite your signature on this form. If you are filing electronically, scan the form after signing it and then file electronically. Note: Bank statements, checks, receipts, stubs, and other items evidencing receipt of funds and payment must be available to the court on demand. May 2014 Rule 7.11 — Form 5 Page 2 of 2