Fill and Sign the Iowa Annual Report of Conservator Form

Rule 7.11 — Form 4: Annual Report 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. Annual Report of Conservator 1. This 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 se rvice. 5. Balance of cash on hand at the close of this report period: $ . 6. The other assets of the Ward at the close of this report period are: 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 If yes, i nclude 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. Amount of Conservator ’s bond: $ . Surety is: . Company providing bond 10 . Guardian: Check one A.  The name of the Ward’s Guard ian is: Full name: first, middle, last B.  The Ward has no Guardian. If you check B , 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: April 2014 Rule 7.11 — Form 4 Page 1 of 2 Rule 7.11 — Form 4 : Annual Report of Conservator , continued 11. Other information relating to affairs of the conservatorship: If conservatorship has special circumstances that do not adapt to this form, include attach ment “F,” setting out special circumstances in detail. 12 . F ees for Conservator are :  hereby applied for  waived. Attach Affidavit per Iowa Code section 633.202. 13. Fees for Conservator 's attorney: Check one  should be set by the court.  are not requested.  are waived or not applicable. Attach Affidavit per Iowa Code section 633.202, if fees requested. 14. Oath and Signature I, , have read this Report, and I certify under Print Conservator’s name penalty of perjury and pursuant to the laws of the State of Iowa that the information I have provided in this 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 ar e 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. April 2014 Rule 7.11 — Form 4 Page 2 of 2