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JDF 882 SC R6/19 CONSERVATOR’ S FINANCIAL PLAN WITH INVENTORY AND MOTION FOR APPROVAL Page 1 of 11 ❑ District Court ❑ Denver Probate Court ___________________ County, Colorado Court Address: In the Interest of: Protected Person COURT USE ONLY Attorney or Party W ithout Attorney (Name and Address): Phone Number: E-mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom CONSERVATOR’S FINANCIAL PLAN WITH INVENTORY AND MOTION FOR APPROVAL ❑ INITIAL REPORT INVENTORY VALUES AS OF DATE OF APPOINTMENT ❑ AMENDED REPORT INVENTORY VALUES AS OF DATE _____________ ( MM/DD/YYYY) DATE OF APPOINTMENT _____________ ( MM/DD/YYYY) FILING DUE DATE ________________ (MM/DD/YYYY) I, (conservator) , move this court to approve this ❑ Initial ❑ Amended Conservator’s Financial Plan with Inventory . As grounds therefore, the conservator states the following: 1. The information contained in the Financial Plan with Inventory is true and complete. The proposed plan is necessary to protect and manage the income and assets of the Protected Person. 2. The Financial Plan is based on the actual needs and best interest of the protected person. I understand that I am re quired to maintain supporting documentation for all receipts and disbursements including detailed billing statements from any professional. The court or any interested person as identified in the Order Appointing Conservator may request copies at any time. I understand that I must pr ovide copies of this Financial Plan with Inventory to the protected person and any others as identified in the Order Appointing Conservator , within 10 days of filing with the court and will indicate having done so by completing the certificate of service a t the end of this form . (§ 15 -14 -404(4), C.R.S.) Unless the court receives a timely objection to this motion, this matter will be considered unopposed and reviewed by the court. Notice to interested persons. Interested persons have the responsibility to protect their own rights and interests within the time and in the manner provided by the Probate Code, including the appropriateness of disbursements, the compensation of fiduciaries, attorneys, and others, and the distribution of estate assets. Interested persons may file an objection with the court. The court may not review or adjudicate these or other matters unless specifically requested to do so by an interested person. JDF 882 SC R6/19 CONSERVATOR’ S FINANCIAL PLAN WITH INVENTORY AND MOTION FOR APPROVAL Page 2 of 11 PART A: CONTACT INFORMATION Prot ected Person’s Information: ❑ Check if updated information from petition Name: ____________________________________________________ Age : ________ (Include Name of Living Center or Nursing Home , if applicable ) Street Address: __________________________________________________________________________ City: State: Zip Code: Mailing Address, if differnty: ________________________________________________________ ___ City: ___________________ State: ______________ Zip Code: _________________ Primary Phone : Alternate Phone: _____________________ Conservator’s Information: ❑ Check if updated information from petition Name: ____________________________________________________ Age: _______________ Have you had any criminal charges filed against you or convictions entered since the last report? ❑Yes ❑ No If Yes, explain: ____________________________________________ _________________________________ Occupation: _____________________ Your Relationship to protected p erson: __________________________ Street Ad dress: ___________________ _________________________________________ City: ___________________ State: ______ Z ip Code: _________ Mailing Address, if different: ___________________________________________________________ City: ________________ State: ___________ Zip Code: _____________ Primary phone ___________________ Alternate Telephone: ______ __________ _ Email a ddress: ___________________ Co -Conservator’s Information: (if applicable) ❑ Check if Updated Information from Petition Name: ____________________________________________________ Age: ____________ Have you had any criminal charges filed against you or convictions entered since the last Petition? ❑Yes ❑ No If Yes, explain: ______________________________________________________________________________ Occupation: _____________________ Your Relationship to Protected Person: ________________________ _ Street Ad dress: ___________________ _________________________________________ City: ___________________ State: ______ Zip Code: _________ Mailing Address, if different: ___________________________________________________________ City: ________________ State: ___________ Zip Code: _____________ Primary phone ___________________ Alternate Telephone: _________________ Email address: ___________________ PART B: CONSERVATORSHIP ISSUES 1. Are the assets in the estate identified to date sufficient to provide for the present and future care of the Protected Person? ❑ Yes ❑ No If No , describe why and what steps should be taken. If you would like the Court to take action, you must file a motion with the Court. JDF 882 SC R6/19 CONSERVATOR’ S FINANCIAL PLAN WITH INVENTORY AND MOTION FOR APPROVAL Page 3 of 11 2. Should there be a change in scope of the Conservatorship? ❑ Yes ❑ No If Yes , describe why and what steps should be taken. If you would like the Court to take action, you must file a motion with the Court. 3. ❑ Bond has been set in the amount of $ ___________________ . Sure ty has been posted. ❑ The setting of bond was deferred pending filing of this Conservator’s Financial Plan with Inventory and Motion for Approval. The Conservator now requests that bond be set in the amount of $_____________. ❑ Bond has been waived by the Court. INSTRUCTIONS ON HOW TO COMPLETE THIS FORM The Financial Plan and Inventory must be filed with the Court pursuant to §§15 -14 -418 and 15 -14 -419 , C.R.S. Step s 1 and 2 are a projection of the Protected Person’s annual income and expenses. Enter both the anticipated monthly and annual amounts in the respective columns. Step 3 is an inventory of the Protected Person’s assets. Provide a detail ed description of the asset as well as the current fair market value. Step 4 summarizes all costs and expenses incurred by the estate related to this proceeding. Step 5 summarizes all debts of the estate. Provide a detail ed description as well as t he remaining amount due. Step 6 and 7 are a summary. Transfer the respective income and expense totals from Steps 1 and 2 as well as the asset and liability totals in steps 3 through 5 to the appropriate lines in Step 7 to calculate the net income and net worth. PART C: FINANCIAL PLAN List all expected sources of receipts/income and disbursements/expenses in the charts below. If a specific category is not applicable, indicate “0” in the projected monthly and annual amounts columns. You will use these amounts when you file the initial Conservator’s Report. Step 1: Projected Receipts/Income Indicate the amount of cash receipts/income received on both a monthly and annual basis. If an income amount (such as wages) is to be received on a monthly basis, multiply the amount by 12 to determine the projected annual amount. If an income amount (suc h as dividends) is to be received on an annual basis, divide the amount by 12 to determine the projected monthly amount. Description of Receipt/Income Category Projected Monthly Amount Projected Annual Amount Asset Not Previously Reported Business Income Court Order Repayment Disability /Unemployment /Worker’s Compensation Distribution – Annuity Distribution – Pension s/Retirement Plan Distribution - Trust JDF 882 SC R6/19 CONSERVATOR’ S FINANCIAL PLAN WITH INVENTORY AND MOTION FOR APPROVAL Page 4 of 11 Farm/Ranch Income Gifts from Others Inheritance Insurance Settlement/Benefit Interest/Dividends Loan Repayment Oil/Gas/Mineral Royalties Other Public Assistance Other Receipts/Income Proceeds from Sale of Assets Rental Income Reverse Mortgage Payment Social Security Tax Refunds VA Benefits Wages Total Receipts/Income Enter the total projected monthly and annual amounts in Step 6. Step 2: Projected Disbursements/Expenses Indicate the cash disbursement/expense amount on both a monthly and annual basis. If an expense (such as utilities) is to be paid on a monthly basis, multiply the amount by 12 to determine the projected annual amount. If an expense (such as property taxe s) is to be paid on an annual basis, divide the amount by 12 to determine the projected monthly amount. Description of Disbursement/Expense Category Projected Monthly Amount Projected Annual Amount Assisted Living/Care Facility Bank/Investment Account Fees Caregiver/In -Home Provider Charitable Contributions Clothing Collectibles Debt Repayment (excluding CC) Debt Repayment (Credit Card) Distributions -Protected Person Education/Tuition/Student Loan JDF 882 SC R6/19 CONSERVATOR’ S FINANCIAL PLAN WITH INVENTORY AND MOTION FOR APPROVAL Page 5 of 11 Entertainment/Movies Equipment Farm/Ranch Expense Fees –Accountant/CPA Fees -Conservator –Non Prof Fees –Conservator –Prof essional Fees –Court Visitor Fees -Guardian –Non Prof Fees -Guardian –Prof essional Fees -Guardian Ad Litem (GAL) Fees -Investment Acct Management Fees -Legal for Conservator Fees -Legal for Guardian Fees –Legal for GAL Fees –Legal for Protected Person Fees –Other Professional Funeral Gifts Groceries/Hygiene/Household Supplies HOA Fees Hobbies Home Furnishings Insurance – Home/Renter Insurance – Life Insurance – Long Term Care Insurance – Other Jewelry Livestock Loan Interest Loans Medical -Doctor/Prof/Hospital Medical - Furnishings/Supplies Medical -Insurance Medical -Medicab/Transportation Medical -Medications Medical -Other Mortgage Motor Vehicle - Insurance Motor Vehicle – Loan Payments JDF 882 SC R6/19 CONSERVATOR’ S FINANCIAL PLAN WITH INVENTORY AND MOTION FOR APPROVAL Page 6 of 11 Motor Vehicle – Registration/Other Motor Vehicle – Repairs/Maint/Fuel Moving Expenses Other Disbursement/Expense Other Transportation Pet Care Property Repairs/Maintenance Rent Restaurants/Dining Out School Supplies Services - Cleaning Services - Personal Care Subscriptions/Dues Taxes – FICA and Medicare Taxes – Income Taxes – Property and Assessments Travel/Vacations Utilities (Including Phone/Cell) Total Disbursements/Expenses Enter the total projected monthly and annual amounts in Step 6. $ $ INVENTORY Step 3: Current Assets Report the fair market value of each category of asset in the chart below as of date of appointment . By indicating “None”, you are stating affirmatively that the Protected Person does not have assets in that category. Note: If additional space is neede d, separate sheets may be used. If additional items are discovered after the initial inventory has been completed, a supplemental inventory listing those additional item(s) must be completed. Cash on Hand, Bank, Checking,Savings , Certificate of Deposits, and Health Accounts (Name of Bank or Financial Institution) ❑ None Payable on Death Type of Account Account # (last 4 - digits only) Balance $ Total $ JDF 882 SC R6/19 CONSERVATOR’ S FINANCIAL PLAN WITH INVENTORY AND MOTION FOR APPROVAL Page 7 of 11 Stocks, Bonds, Mutual Funds, Securities , Annuities and Investment Accounts (Name of Joint Owner or Transfer on Death Beneficiary) ❑ None Number of Shares or Identify Account Number (last 4 -digits only) Current Value $ Total $ Life Insurance (Name of Company/Beneficiary) ❑ None Type of Policy Face Amount of Policy Cash Value $ Total $ Pension, Profit Sharing and Retirement Funds (Name of Beneficiary) ❑ None Type of Plan (401(k), IRA, 457, PERA, Military, etc.) Account # (last 4 -digits only, if applicable) Current Account Value (Note: Distributions should be listed in Step 1 above) $ Total $ Motor Vehicles and Recreation Vehicles (Including Motorcycles, ATV’s, Boats, etc.) (Names of Joint Owners) ❑ None Year Make and Model Estimated Value (Value = what you could sell it for in its current condition) $ Total $ Real Estate (Indicate address) (Name any Joint Owners) ❑ None Type of Property (Home, Rental, Land, etc.) Estimated Value (Value = what you could sell it for in its current condition) $ JDF 882 SC R6/19 CONSERVATOR’ S FINANCIAL PLAN WITH INVENTORY AND MOTION FOR APPROVAL Page 8 of 11 Total $ General Household and Other Personal Property ❑ None Estimated Value (Value = what you could sell it for in its current condition) General Household and Other Personal Property (Total value except for items listed below.) $ Separately list and value items of significant value below, for example: Jewelry, Antiques, Collectibles, Artwork, etc. Total $ Miscellaneous Assets (List each one separately and be specific.) ❑ None Estimated Value (Value = what you could sell it for in its current condition) $ Total $ Total Assets Enter this amount in Step 7. $ Step 4: Accrued Liabilities to Professionals The conservator requests that the accrued expenses of this proceeding as of date of appointment as detailed below be approved by the court as identified in Step 2. Type of Professional and Name of Individual Amount Billed Account Manage ment - Professional $ Accountant/CPA Conservator -Non Professional Conservator -Professional Court Visitor Guardian -Non Professional Guardian - Professional Guardian Ad Litem (GAL) Legal Fees - Conservator Legal Fees - Guardian Legal Fees - GAL Legal Fees - Protecte d Person Other Professional Fees JDF 882 SC R6/19 CONSERVATOR’ S FINANCIAL PLAN WITH INVENTORY AND MOTION FOR APPROVAL Page 9 of 11 Total Accrued Expenses Enter totals below in Step 5 - Inventory of Liabilities/Debts. $ Step 5: Other Current Liabilities /Debts Report the value of each liability /debt in the chart below as of date of appointment as identified in Step 2 . Description of Liability /Debt ❑ None Name of Creditor Account Number (last 4 -digits only) Balance Accrued expenses associated with this proceeding (Total Step 4 above ) $ Mortgage (principal due only) Motor Vehicle Loan 2nd Mortgage /Home Improvement Student Loan /Tuition Credit Card Federal Taxes State / Local Taxes Other Loan/ Liabilit y/Debt (Please list) HELOC Reverse Mortgage Total Liabilities /Debt Enter this amount in Step 7. $ Summary Step 6: Summary of Financial Plan (Receipts/Income Minus Disbursements/Expenses) Summarize the Financial Plan below after comp leting the detailed ac counting information in Step 1 and Step 2. Projected Monthly Projected Annual Amount Amount (A) Receipts/ Income (Total from Step 1 ) $ _____________ $ _____________ (B) Disbursements/ Expense s (Total from Step 2) $ _____________ $ _____________ Net Income: (A) minus (B) $ _____________ $ _____________ Step 7: Summary of Inventory Summarize the Inventory below after completing the detailed accounting information in Step 3 and Step 5. (A) Total Assets (Total from Step 3 ) $ _____________ (B) Total Liabilities/Debt (Total from Step 5) $ _____________ Net Worth : (A) minus (B) $ _____________ JDF 882 SC R6/19 CONSERVATOR’ S FINANCIAL PLAN WITH INVENTORY AND MOTION FOR APPROVAL Page 10 of 11 Bond ❑ Bond has been set in the amount of $ ___________________ . Sure ty has been posted. ❑ The setting of bond was deferred pending filing of this Conservator’s Financial Plan w ith Inventory and Motion for Approval . The Conservator now requests that bond be set in the amount of $___________________. (§15 -14 - 415, C.R.S.) ❑ Bond has been waived by the Court. ❑ By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form. ❑ By checking this box, I am acknowledging that I have made a change to the original content of this form. IMPORTANT This document must be signed and dated by all conservators and served on the protected person and all interested parties, as indicated by the attached certificate of service. A conservator is required to file an amended “Financial Plan” whenever there is a change in circumstances that requires a substantial deviation from the existing plan. In addition, if the conservator finds other property not included in the original “Invento ry”, or if the value of the listed property is inaccurate or misleading , the conservator must prepare and file an amended “Inventory” with the court. Copies of these amendments must be provided to all interested parties. § 15 -14 -418(5) C.R.S. § 15 -14 - 419(2 ) C.R.S. THIS SECTION MUST BE COMPLETED CORRECTLY AND SIGNED OR THE DOCUMENT MAY BE REJECTED. Colorado Law REQUIRES that the Conservator’s Financial Plan with Inventory and Motion for Approval be served on the PROTECTED PERSON AND INTERESTED PERSONS pur suant to the Order Appointing Conservator, including minors 12 years of age or older (§ 15 -14 -404(4), C.R.S.). In the space below, list the names, addresses, and method of delivery for each party listed on the Order Appointing Conservator and provide each party with a copy of this document. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the ______ day of Executed on the ______ day of (date) (date) _______________________, _________, _______________________, _________, (month) (year) (month) (year) at ______________________________________ at ______________________________________ (city or other location, and state OR country) (city or other location, and state OR country) _______________________________ _______________________________ (printed name) (printed name) _______________________________ _______________________________ (Signature of Conservator/Successor) (Signature of Co -Conservator/Successor, if any) _________________________________________ __________________ Attorney Signature, (if any) Date JDF 882 SC R6/19 CONSERVATOR’ S FINANCIAL PLAN WITH INVENTORY AND MOTION FOR APPROVAL Page 11 of 11 CERTIFICATE OF SERVICE I certify that on ___________________ (date), a copy of this _______________ (name of document) was served as follows on each of the following: Name and Address Relationship to Decedent, Ward, or Protected Person Manner of Service* *Insert one of the following: hand delivery, first -class mail, certified mail, e -service, or fax. _____________________________________________ Signature