Notice of Petition for Appointment

Guardian’s Account

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: , a disabled person

Court of Chancery C.M. #

GUARDIAN’S ACCOUNT

Accounting Number: Please circle or fill-in the appropriate number

Accounting Period: to

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 Rule 180(b), the attached status report must also be filed (with the Doctor’s signature).

Annual Update & Medical Statement

I, , was appointed Guardian of

on

1. My current mailing address is 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 disabled person’s financial affairs:

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:

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:

Physician’s Statement

The attending physician, last examined

on the following date

Describe physical health of the disabled person/diagnosis:

Significant changes since last review:

Hospitalizations/Surgical procedures since last review:

Consequently, there is a continued need for guardianship of the disabled person:

Yes No

If No, why not?

Additional Information Regarding Accountings

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. Spreadsheets can be filed as an attachment to any schedule.

Please make sure to supply the name, relationship and current address of all next-of-kin (interested parties).

The Guardian(s) signature(s) is/are to be notarized on either the C-16-A or C-16-B form.

The Guardian(s) is/are also required to provide cancelled checks, bank statements, receipts and any other pertinent information to show how the disabled person’s money was used.

Supporting documents are not kept by the Register in Chancery after review.

As the guardian(s), I wish for all supporting documentation to be:

Shredded by the Register in Chancery Clerk

Returned to the guardian

I have read the accounting instructions.

Summary

Schedule A - Principal on Hand:

Schedule B - Additions to Principal:

Schedule C - Income Received:

Total:

Schedule D - Deductions from Principal:

Schedule E - Income Paid Out:

Total:

Schedule 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.

Schedule A

Amount of principal on hand on

Description of asset / Value

Schedule B

Additions to principal, when made, and the source from which they were obtained.

Schedule C

Income received, when received and from what source.

Schedule D

Deductions from principal, when made and for what purpose.

Schedule E

Income paid out/expenses paid, to whom, when paid, and for what purpose.

Schedule F

Principal on hand at the end of the accounting period.

List of Beneficiaries/Interested Parties

List any and all next-of-kin and beneficiaries over the age of eighteen.

Waiver of Notice and Consent

Next-of-kin may sign the attached waiver of notice and consent to the accounting.

If no consent is attached, the Clerk will mail notice to them.

Final / Non-Final Accounting Certification

Guardian:

Guardianship Case #

IMO

Sworn to and subscribed before me this day of A.D. 20

(Section below to be completed by the Court)

I, , do hereby certify that I have examined the foregoing account, tried the calculations and additions, compared the vouchers and find the same correct as shown.

And further, that on the day of A.D. 20 , I did send by mail to the beneficiary(ies) at their addresses 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 .

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.

CHANCELLOR/VICE CHANCELLOR/MASTER