Fill and Sign the Free in the Superior Court for the State of Alaska in the Form

Probate Rule 17(e) AS 13.26.505 & 13.06.100 Page 1 of 8 PG-220 (6/17)(cs) CONSERVATOR’S IMPLEMENTATION REPORT & INVENTORY IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT____________________ In the Matter of the Protective Proceedings of: ) ) ) (Name of Protected Person) ) Date of Birth: ) ) Residential location of Protected Person: ) ) ) CASE NO. Protected Person’s Telephone #: ) ) ) CONSERVATOR’S IMPLEMENTATION REPORT AND INVENTORY Instructions Please type or print clearly using black ink. In preparing the report, you must consult with the protected person as much as possible. The court will treat the information in this report as confidential. If you are unable to complete this form without help, you may find assistance on the website of the Office of Public Advocacy (OPA): http://doa.alaska.gov/opa/pg/pub_guard.html . Your local library and court may also have a binder of helpful information entitled “Family Guardian Education Materials, ” prepared by the Alaska State Association for Guardianship and Advocacy. You may also call OPA at 269-3500 (in Anchorage), 451-5933 (in Fairbanks) or 1- 877-957-3500. After completing this report, you must sign it under oath (or affirmation) in the presence of a notary public or court clerk. See last page. The purpose of this report is to give the court as complete a picture as possible of the protected person’s current financial situation. Information About Conservator Conservator’s Name Daytime Phone Mailing Address (box or street number) (city) (state) (ZIP) Check here if this mailing address is new. If you change your address, please notify the court. Residence Address (street address) (city) (state) Do you live with the protected person? Yes No Relationship to protected person: Has a separate guardian been appointed for the person? No Yes Name: Probate Rule 17(e) AS 13.26.505 & 13.06.100 Page 2 of 8 PG-220 (6/17)(cs) CONSERVATOR’S IMPLEMENTATION REPORT & INVENTORY If you are a private conservator charging fees, is there a court order authorizing payment of fees and establishing an hourly rate and maximum monthly amount as required by Probate Rule 17 and AS 08.26.110? Yes No I do not charge fees. Information About Protected Person 1. Housing . Describe where the protected person lives: Name of facility or place: Address: (street address) (city) (state) (ZIP) Type of Residence: nursing home assisted living home If the protected person lives in your home, do you charge him/her rent? Yes No If you live in the protected person’s home, are you paying him/her rent? Yes No 2. School and Job Training . Does the protected person attend school or any type of job training? Cost: 3. Work. Is the protected person employed? No. Yes. Describe (include type of work, name of employe r, address, phone, and how long employed): 4. Contacts . Describe your contacts with the protected person since you were appointed conservator: Type of Contact How Often in person by telephone by mail or e-mail through 3rd person: other: 5. Decision Making . When a decision has to be made about the protected person’s financial affairs, how are the decisions made? a. Describe decisions made by protected person alone: b. Describe decisions made by conservator alone: c. Describe decisions made by conservator and protected person together: Probate Rule 17(e) AS 13.26.505 & 13.06.100 Page 3 of 8 PG-220 (6/17)(cs) CONSERVATOR’S IMPLEMENTATION REPORT & INVENTORY 6. Dependents . (List anyone the protected person is legally required to support.) Name Relationship to Person Date of Birth (if under 18) 7. Conservator Services . a. Briefly describe the conservator services you plan to provide to the protected person: b. What are you doing or planning to do to help the protected person learn to manage and protect his/her money? 8. Protected Person’s Current Monthly Income. (List only the income of the protected person. Do not list any of your own income. Divide any yearly amounts by 12. Divide quarterly amounts by 3.) Income Source Monthly Amount Social Security Benefits: a. SSA b. SSI Adult Public Assistance: Veterans Financial Benefits: Alaska Longevity Bonus: Permanent Fund Dividend: Native Corporation Dividend: Wages: Dividends/Interest: Rental Income: Pension: Annuities: Other: (describe) Total Monthly Income: Probate Rule 17(e) AS 13.26.505 & 13.06.100 Page 4 of 8 PG-220 (6/17)(cs) CONSERVATOR’S IMPLEMENTATION REPORT & INVENTORY 9. Protected Person’s Monthly Expenses. (Money paid to anyone on behalf of the protected person or the protected person’s legal dependents. Divide yearly amounts by 12. Attach extra pages if necessary.) Monthly Expense Description Amount Nursing/Assisted Living Home: Rent Payment: Mortgage Payment: Utilities: Transportation: Medical Treatment Costs: Medications: Credit Card Payments: Food: Clothing: Recreation or Entertainment: Personal Expenses (include allowance): Income Tax & Property Tax: Home/Property Maintenance Costs: Insurance: Home Insurance Auto Insurance Medical Insurance Life Insurance Gifts: Child/Spousal Support: Fees/Costs Paid to Conservator: Other (list all other payments made): Total Monthly Expenses: 10. Protected Person’s Assets on (date). (List all assets the person owns individually or jointly. Attach extra pages if necessary.) a. Cash on hand (not in an account) $ (amount) (where located) b. Burial Account Name of Bank or Institution Type of Account Account Number Balance c. Alaska Native Corporation Dividend Account Name of Bank or Institution Type of Account Account Number Balance Probate Rule 17(e) AS 13.26.505 & 13.06.100 Page 5 of 8 PG-220 (6/17)(cs) CONSERVATOR’S IMPLEMENTATION REPORT & INVENTORY d. List all other bank accounts, certificates of deposit, etc. Attach the most recent bank statement. Attach additional pages if necessary. Name of Bank or Institution Name(s) on Account Account Number Balance e. List all Brokerage Accounts, Stocks, Bonds, and Other Securities. Attach the most recent account statement. Attach additional pages if necessary. Name of Company Name(s) on Account Account Value on (date) f. Retirement Accounts. Name of Company Beneficiary Current Value g. Life Insurance Policies (policies the protected person owns). Name of Company Beneficiary of Life Insurance Face Value of Life Insurance Cash Value of Life Ins. h. Real Estate that Protected Person Owns (land and buildings). Attach tax assessment, if available. (1) Does protected person own a home? No Yes Estimated Value: $ Address: Description: Is there a joint owner? No Yes (2) Other Real Estate. Estimated Value: $ Address: Description: Is there a joint owner? No Yes Probate Rule 17(e) AS 13.26.505 & 13.06.100 Page 6 of 8 PG-220 (6/17)(cs) CONSERVATOR’S IMPLEMENTATION REPORT & INVENTORY i. Vehicles. (List any cars, boats, snow machines, off-road vehicles, airplanes, etc.) Type of Vehicle Year, Make & Model Value Co-Owner j. Furniture, Appliances and Electronic Equipment exceeding $400 in value. Attach additional pages if necessary. Description of Item Approximate Age Value k. Jewelry, Gems, Precious Metals, Coin or Stamp Collections, Other Collections, Artwork, Raw or Decorated Ivory. Attach additional pages if necessary. Description of Item Location Value l. Other Personal Property. (List any item that has a value over $400. Please include any collectibles and any other items that are particularly susceptible to theft. Give details sufficient to allow a third party to identify the item. Attach extra pages, if necessary.) Description of Item Location Value m. Commercial Fisheries Interests (IFQs or limited entry permits). ValueTOTAL ASSETS (Total value of all items in #10 a through m) $ Probate Rule 17(e) AS 13.26.505 & 13.06.100 Page 7 of 8 PG-220 (6/17)(cs) CONSERVATOR’S IMPLEMENTATION REPORT & INVENTORY 11. Protected Person’s Liabilities. (List all debts the protected person owes, including mortgages, loans, credit card debt, etc. Attach extra pages if necessary.) a. Real Estate Debts. (1) Home described in #10(h )(l). Loan balance: $ (2) Property described in #10(h )(2). Description: Loan balance: $ b . Other Loans. Lender (Name & Address) Purpose (loan type) Loan Number Balance Due c . Credit Cards. Company (Name & Address) Card Card Number Balance Due d. Judgments/liens. Description Balance Due e. Amounts Owed For Services. Service To Whom Owed Balance Due (1) Medical Services (2) Attorney Services (3) Conservator Services (4) Other TOTAL LIABILITIES (Total all items in #11 a through e): $ 12. NET ASSETS (Subtract Total Liabilities from Total Assets): Total Assets from 10 a - m. $ Total Liabilities from 11 a - e $ Net Estate Value $ 13. Trusts. The protected person is a beneficiary of the following trust(s) (meaning the person has the right to receive benefits of some kind from the trust): Name of Trust: Name and Address of Trustee: Probate Rule 17(e) AS 13.26.505 & 13.06.100 Page 8 of 8 PG-220 (6/17)(cs) CONSERVATOR’S IMPLEMENTATION REPORT & INVENTORY If registered with the court, list trust registration no. State Do you know what benefits the protected person is supposed to receive from the trust? Yes No Is the protected person receiving the benefits from the trust that he/she is supposed to receive? Yes No I do not know. 14. Did the protected person help you prepare (provide information for) this report? Yes No Oath I do solemnly swear (or affirm) that the information given in this report is true and correct to the best of my knowledge and belief. Date Conservator’s Signature Subscribed and sworn to or affirmed before me at , Alaska on , 20 . (SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: I certify that on , I gave a copy of this report and its attachments to: protected person protected person’s attorney or guardian ad litem (if currently representing p rotected person): parent or guardian with whom protected person resides (if any): protected person’s guardian (if a separate guardian has been appointed): the following person(s) designated by cou rt order: Conservator’s Signature