Fill and Sign the Georgia Conservatorship Form

GEORGIA PROBATE COURT STANDARD FORM Adult Conservatorship Inventory and Asset Management Plan INSTRUCTIONS I. Specific Instructions 1. This form is to be used pursuant to O.C.G.A. §29-5-30. II. General Instructions General instructions applicable to all Georgia probate court standard forms are available in each probate court. Effective 7/07 2 GPCSF 58 Complete GEORGIA PROBATE COURT STANDARD FORM 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 County State Approximate equity Parcel 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: _____________________________________________________ _____________________________________________________________________________________ Effective 7/07 2 GPCSF 58 Complete PERSONAL AND INTANGIBLE PROPERTY (Indicate if property is jointly owned and with whom) Approximate Current Value 1. 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 Institution Acct. No. Joint Owner (if any) $ __________________ $ __________________ $ __________________ $ __________________ $ __________________ b. privately held: Company/Issuer No. of Shares Joint Owner (if any) $ __________________ $ __________________ 3. Automobiles: Year/Make/Model V.I.N. Joint owner (if any) $ __________________ $ __________________ 4. Other assets of significant value: Description Joint owner (if any) $ __________________ $ __________________ $ __________________ TOTAL VALUE OF PERSONAL AND INTANGIBLE PROPERTY $ __________________ Effective 7/07 2 GPCSF 58 Complete 3 DEBTS AND OTHER LIABILITIES The ward owes the following debts/liabilities: 1. Secured debts: Obligor/Payee Collateral Solely/Jointly Owed Approx. Current Balance $___________________ $___________________ 2. Unsecured debts: Obligor/Payee Acct. 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) $ _____________________ Effective 7/07 2 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: ________________________________________________ _________________________________________________________________________ _________________________________________________________________________ Effective 7/07 2 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 before me this day of , 20 . ________________________________________ Conservator ________________________________________ NOTARY/CLERK OF PROBATE COURT Printed Name My Commission Expires__________________ --------------------------------------------------------------------------------------------------------------------------- Sworn to and subscribed before me this day of , 20 . ________________________________________ Co-Conservator, if any ________________________________________ NOTARY/CLERK OF PROBATE COURT Printed Name My Commission Expires____________________ Effective 7/07 2 GPCSF 58 Complete 6 IN THE PROBATE COURT OF COUNTY STATE OF GEORGIA IN RE: ) ESTATE NO. _______________________ ) , ) ASSET MANAGEMENT PLAN WARD ) ) , ) CONSERVATOR(S) ) ORDER The Conservator(s) having filed an Asset Management Plan for the above estate, it is hereby ORDERED 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