Fill and Sign the Instructions to Conservator Form

Page 1 of 11 PG-230 (2/05)(cs) Probate Rules 17(f) & (h) AS 13.26.510, .545(e), .570 & 13.06.100 FINAL CONSERVATORSHIP REPORT IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Pr otective Proceedings of: ) ) ) ( Name of Protected Person ) ) ) Date of Birth: ) ) Residential location of Protected Person: ) ) ) CASE NO. Protected Person’s Telephone #: ) ) FINAL CONSERVATORSHIP REPORT Instructions To Conservator Please type or print clearly using black ink. In preparing the report, you must consult with the protected pe rson as much as possible (if the protect ed person is still living). The court will treat the information in this report as confidential. If you are unable to complete th is form without help, you may fi nd assistance on the website of the Office of Public Advocacy (OPA): www.s tate.ak.us/guardianship . Your local library and court may also have a binder of helpful information entitled “ Family Guardian Education Materials, ” prepared by the Alaska State Associati on 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 unde r oath (or affirm ation) in the presence of a notary public or court clerk. See last page. The purpose of this report is to tell the court why your service as conservator is ending and what has happened to the protected person and the prot ected person’s assets since you filed your last annual report. Reporting Period This report covers the period: From the end of the last reporting period: To the date my services as conservator ended: 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. Relationship to protected person: Was a separate guardian appointed for the person? No Yes Name: Page 2 of 11 PG-230 (2/05)(cs) Probate Rules 17(f) & (h) AS 13.26.510, .545(e), .570 & 13.06.100 FINAL CONSERVATORSHIP REPORT Reason For Ending Conservatorship My conservatorship of the protected person has ended because: The protected person died on at date) (location) A copy of the death certificate is attached. I did did not have possession of the protected person’s will. On , 20 , I delivered the protecte d person’s will to the court for safekeeping, as required by AS 13.26.545(e), and informed the executor o r a beneficiary named in the will that the will had been so delivered. N\ ame of p erson notified: I resigned as conservator. A new conservator, , has been appointed. (name) I was removed by the court. The court has terminated the conservatorship because Other (Explain): If the protected person is deceased or if th e conservatorship has been terminated because the protected person regained the ability to manage his/her pr operty and affairs, you need not fill out paragraphs 1-6. Skip to paragraphs 7 - 16. Information About Protected Person 1.Housing . Where does the protected person live now (name of facility or place)? Who takes care of th e protected person? Type of Residence: nursing home assisted living home 2.Medical Care . a. Describe in general terms the nature of the protected person’s medical expenses during the reporting period (ser v ices received and cost). b. Has there been a significant change in these expe nses from the prior year? Yes No Explain: Page 3 of 11 PG-230 (2/05)(cs) Prob ate Ru les 17(f) & (h) AS 13.26.5 10, .545(e), .5 70 & 13.06.1 00 FINAL CONSERVATORSHIP REPORT 3. School and Job Training . Since the last report to the court, did the protected person attend school or receive any type of job training? No Yes. Describe studies (include name and location of school): Cost: 4. Work. Was the protected person employed at any tim e during the period since the last report to the court? No Yes. Describe (include type of work, name of employer, address, phone, and how long employed): 5. Contacts With Protected Person . Describe your contacts with the protected pe rson in the period since your last report to the court: Type of Contact How Often in person by telephone by mail or e-mail through 3rd person: other: 6. Decision Making . Have there been any changes in the protected person’s ability to make\ decisions on financial matte rs? 7. Significant Actions. Describe any significant actions you took as conservator for the protected person during the period since your la st report was filed with the cour t (including an y actions taken regarding the protecte d property and funds): Page 4 of 11 PG-230 (2/05)(cs) Prob ate Rules 17(f) & (h) AS 13.26.510, .545(e), .570 & 13.06.100 FINAL CONSERVATORSHIP REPORT 8. Additional Information . List any additional inform ation about the protected person that you wish to report to the court: 9. Protected Person’s Income Since Last Annual Report. (L ist only the income of the protected person. Do not list your income.) Amount Received Since Last Income Source Annual Report 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 Inco me: Pension: Annuities: Other (describe): Total Income Received Since Last Annual Report: Page 5 of 11 PG-230 (2/05)(cs) Prob ate Ru les 17(f) & (h) AS 13.26.5 10, .545(e), .5 70 & 13.06.1 00 FINAL CONSERVATORSHIP REPORT 10. Protected Person’s Expenses Since Last Annual Report. (Money paid to anyone on behalf of protected person or his/her legal dependents. Do not include your personal expenses. Attach extra pages if necessary.) Amount Spent Since Last Expense Description Annual Report Nursing/ Assisted Living Home: Rent Paym ent: Mortgage P ayment: Utilities: Transportation: Medica l Treatment Costs: Medications: Credit Card Payments: Food: Clothing: Recreation or Entertainment: Personal Expenses (include allowance): Income Tax/Property Tax: Home /Property Maintenance Costs: Insurance Hom e Insurance: Auto Insura nce: Medical Insurance: Life Insuran ce: Gifts: Child/Spousal Support: Fees/Costs Paid to Conservato r: Burial Expenses: Other (lis t all othe r payments made): Total Expenses Since the Last Annual Report: 11.Money Controlled By Protected Person. Since the last annual report was filed, did the protected person have sole control over any money? Yes No If yes, please explain: Is this mone y included in the income and expenses listed in #9 and #10? Yes No Explain: Page 6 of 11 PG-230 (2/05)(cs) Prob ate Ru les 17(f) & (h) AS 13.26.5 10, .545(e), .5 70 & 13.06.1 00 FINAL CONSERVATORSHIP REPORT 12. Protected Person’s Assets on the following date: . (List all assets the person owned individually or jointly. Attach extra pages if necessary.) a.Cash on hand (not in an account) $ (amount) (where located) Explain any changes since last report: b. Burial Account Nam e of Bank or Institution Type of Account Account Number Balance Explain any changes since last report: c. Alaska Native Corporation Dividend Account Nam e of Bank or Institution Type of Account Account Number Balance Explain any changes since last report: d. List all other bank acco unts, certificates of deposit, etc. Attach the most recent bank statement. Attach additional pages if necessary. Nam e of Bank or Institution Name(s) on Account Account Number Balance Explain any changes since last report: Page 7 of 11 PG-230 (2/05)(cs) Prob ate Ru les 17(f) & (h) AS 13.26.5 10, .545(e), .5 70 & 13.06.1 00 FINAL CONSERVATORSHIP REPORT e. List all Brokerage Accounts, Stocks, Bonds, and Other Securities. Attach the most recent account statement. Attach additional pages if necessary. Nam e of Company Name(s) on Account Account Value on (date) Explain any changes since last report: f. Retirement Accounts. Nam e of Company Beneficiary Current Value Explain any changes since last report: g.Life Insuran ce Policies (policies the protected person owns). Nam e of Company Beneficiary of Life Insurance Face Value of Life Insurance Cash Value of Life Ins. Explain any changes since last report: h. Real Estate that Protected Person Ow ns (land and buildings). Attach tax assessment, if available. (1) Does person own a home? No Yes. Estimated Value:$ Address: Description: Is ther e a joint owner? No Yes Explain any changes since last report: Page 8 of 11 PG-230 (2/05)(cs) Prob ate Ru les 17(f) & (h) AS 13.26.5 10, .545(e), .5 70 & 13.06.1 00 FINAL CONSERVATORSHIP REPORT (2) Other Real Estate. Estimated Value: $ Address: Description: Is ther e a joint owner? No Yes Explain any changes since last report: i. Vehicles. (List any cars, boats, snow m achines, off-road vehicles, airplanes, etc.) Type of Vehicle Year, Make & Model Value Co-Owner Explain any changes since last report: j.Furniture, Appliances and Electroni c Equipment exceed ing $400 in Value. Attach additional pages if necessary. Description of Item Approximate Age Value Explain any changes since last report: k.Jewe lry, Gems, Precious Metals, Co in or Stamp Collections, Other Collections, Artwork, Raw or Decorated Ivory. Attach additional pages if necessary. Description of Item Location Value Explain any changes since last report: Page 9 of 11 PG-230 (2/05)(cs) Prob ate Rules 17(f) & (h) AS 13.26.510, .545(e), .570 & 13.06.100 FINAL CONSERVATORSHIP REPORT 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 Explain any changes since last report: m. Commercial Fisheries In terests (IFQs or limited entry permits). Value Explain any changes since last report: TOTAL ASSETS (Total value of all items in #12 a through m) $ Total Assets at End of Previous Reporting Period: $ Change in Total Assets Since Previous Reporting Period: $ 13.Protected Person’s Liab ilities as of . (date) (List all debts the protected person owes . Attach extra pages if necessary.) a.Real Estate Debts. (1) Home described in #12(h)(1). Loan balance: $ Explain any changes since last report: (2) Property described in #12(h)(2). Description: Loan balance: $ Explain any changes since last report: b. Other Loans. Lender (Name & Addre ss) Purpose (loan type) Loan Number Balance Due Explain any changes since last report: Page 10 of 11 PG-230 (2/05)(cs) Probate Ru les 17(f) & (h) AS 13.26.510, .545(e), .570 & 13.06.100 FINAL CONSERVATORSHIP REPORT c. Credit Cards. Company (Name & Address) Card Card Number Balance Due Explain any changes since last report: d.Judgments/liens. Description Balance Due Explain any changes since last report: e.Amounts Owed For Services. Service To Whom Owed Balance Due (1) Medical Services (2) Attorney Services (3) Conservator Services (4) Other Explain any changes since last report: TOTAL LIABILITIES (Total al l items in #13 a through e): $ Total Liabilities at End of Previous Reporting Period: $ Change in Total Liabilities Since Previous Reporting Period: $ 14.NET ASSETS (Subtract Total L iabilities from Total Assets): Total Assets from 12 a - m $ Total Liabilities fr om 13 a - e $ Net Estate Value $ Net Assets at End of Previous Reporting Period: $ Change in Net Assets Since Previous Reporting Period: $ 15. Trusts. The protected person is a beneficiary of the following trust(s) (meaning the person has the right to receive be nef its of some kind from the trust): Name of Trust: Name and Address of Trustee: If registered with the court, list trust registration no. State Do you know what benefits the protected pers on 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. Explain any changes since last report: Page 11 of 11 PG-230 (2/05)(cs) Probate Ru les 17(f) & (h) AS 13.26.510, .545(e), .570 & 13.06.100 FINAL CONSERVATORSHIP REPORT 16. Assets Released. The protected person’s assets were released as follows: To Whom Released Authority of Person To Asset Released Date (Name and Address) Receive This Property * * For authority, list recipient’s role, such as former protected person, new conservator, personal representative of deceased person’s estate, special administrator, temporary property custodian or heir. Oath I do solemnly swear (or af firm) 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 . (SE AL) 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 atto rney or guardian ad litem (if currently representing protected person): parent or guardian with whom protected person resides (if any): protected person’s guardian (if a separate guardian was appointed): the following person(s) designated by court order: Conservator’s Signature