Fill and Sign the Protected Persons Telephone Form

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 #: ) ) CONSERVATOR’S ANNUAL REPORT 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 th is form without help, you may fi nd assistance on the website of the Office of Public Advocacy (OPA): www.state.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 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 s ituation and what has happene d in the last 12 months. Reporting Period This report covers the following period: From To 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: Probate Rule 17(e) AS 13.26.510, .380(b) & 13.06.100 Has a separate guardian been appointed for the protected person? No Yes Guardian’s name: If you are a private conservator ch arging 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. If you are a private professiona l guardian or conservator, do you have professional liability insurance? Yes. (Attach copy of current Declarations page showing liability limits.) No. Changes in Conservatorship Needed • Is there a current need for change in the conservatorship? No Yes If yes, explain: If you want the court to change its order, please file form PG-190. • If this is a Public Guardian appointment, is a suitable private conservator available? No Yes Information About Protected Person 1. Housing . a. 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 b. Has the protected person moved in the past year? Yes No If yes, explain: c. If the person lives in your home, do you charge him/her rent? Yes No If you live in the person’s home, are you paying him/her rent? Yes No 2. Medical Care . a. Describe in general terms the nature of the protected person’s medical expenses during the reporting period (ser vices received and cost). b. Has there been a significant change in these expenses from the prior year? Yes No Explain: Probate Rule 17(e) AS 13.26.510, .380(b) & 13.06.100 3.School and Job Training . Has the protected person atte nded school or any type of job training in the past 12 months? Cost: 4. Work. Has the protected person been employed at any time during the past 12 months? 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 prot ected person in the past 12 months: Type of Contact How Often in person by telephone by mail or e-mail through 3rd person: other: 6. Decision Making . a. Have there been any changes in the pr otected person’s ability to make decisions on financial matters? b. What have you done to help the protect ed person learn to manage and protect his/her money? c. When a decision has to be made about the protected person’s financial affairs, how are the decisions made? (1) Describe decisions ma de by protected person alone: (2) Describe decisions made by conservator alone: (3) Describe decisions made by conser vator and protected person together: Probate Rule 17(e) AS 13.26.510, .380(b) & 13.06.100 7.Significant Actions. Describe any significant actions you have taken as conservator for the protected person during the past 12 months (including any act ions taken regarding the protected person’s property and funds): 8. Protected Person’s Annual Income. (List only income of protected person during the 12-month reporting period, not your income.) Income Source Annual 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 Annual Income: Total Annual Income During Previous Reporting Period: Change in Annual Income Since Previous Reporting Period Explain any difference more than $1000: Probate Rule 17(e) AS 13.26.510, .380(b) & 13.06.100 10.Protected Person’s Annual Expenses. (Money paid to anyone on behalf of protected person or his/her legal dependent s. Do not include your personal expenses. Attach extra pages if necessary.) Expense Description Annual 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 othe r payments made): Total Annual Expenses: Total Annual Expenses During Previous Reporting Period: Change in Annual Expenses Since Previous Reporting Period Explain any difference more than $1000: 11.Money Controlled By Protected Person. Does the protected person have sole control over any money? Yes No If yes, please explain: Is this money included in the income and expenses listed in #9 and #10? Yes No Explain: Probate Rule 17(e) AS 13.26.510, .380(b) & 13.06.100 12.Protected Person’s Assets At End of Reporting Period (Date: ). (List all assets the person ow ns individually or jointly. At tach extra pages if necessary.) a.Cash on hand (not in an account) $ (amount) (where located) Explain any changes in the last 12 months: b. Burial Account Name of Bank or Institution Type of Account Account Number Balance Explain any changes in the last 12 months: c.Alaska Native Corporation Dividend Account Name of Bank or Institution Type of Account Account Number Balance Explain any changes in the last 12 months: 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 Explain any changes in the last 12 months: Probate Rule 17(e) AS 13.26.510, .380(b) & 13.06.100 e.List all Brokerage Accounts, Stoc ks, 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) Explain any changes in the last 12 months: f.Retirement Accounts. Name of Company Beneficiary Current Value Explain any changes in the last 12 months: 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. Explain any changes in the last 12 months: h. Real Estate that Protected Person Owns (land and buildings). Attach tax assessment, if available. (1) Does person own a home? No Yes. Estimated Value: $ Address: Description: Is there a joint owner? No Yes Explain any changes in the last 12 months: Probate Rule 17(e) AS 13.26.510, .380(b) & 13.06.100 (2) Other Real Estate. Estimated Value: $ Address: Description: Is there a joint owner? No Yes Explain any changes in the last 12 months: i.Vehicles. (List any cars, boats, snow machines, off-road vehicles, airplanes, etc.) Type of Vehicle Year, Make & Model Value Co-Owner Explain any changes in the last 12 months: j.Furniture, Appliances and Electroni c Equipment exceeding $400 in value. Attach additional pages if necessary. Description of Item Approximate Age Value Explain any changes in the last 12 months: k.Jewelry, 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 in the last 12 months: Probate Rule 17(e) AS 13.26.510, .380(b) & 13.06.100 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 in the last 12 months: m.Commercial Fisheries Interests (IFQs or limited entry permits). Value Explain any changes in the last 12 months: 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 Liabilities At End of This Reporting Period: (date) (List all debts the protected person owes, in cluding mortgages, loans, credit card debt, etc. Attach extra pages if necessary.) a. Real Estate Debts (1) Home described in #12(h)(1). Loan balance: $ (2) Property described in #12(h)(2). Description: Loan balance: $ Explain any changes in the last 12 months: b. Other Loans. Lender (Name & Address) Purpose (loan type) Loan Number Balance Due Explain any changes in the last 12 months: Probate Rule 17(e) AS 13.26.510, .380(b) & 13.06.100 c. Credit Cards. Company (Name & Address) Card Card Number Balance Due Explain any changes in the last 12 months: d.Judgments/liens. Description Balance Due Explain any changes in the last 12 months: 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 in the last 12 months: TOTAL LIABILITIES (Total all 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 Liabilities from Total Assets): Total Assets from 12 a - m $ Total Liabilities from 13 a - e $ Net Estate Value $ Net Assets at End of Previous Reporting Period: $ Change in Net Assets Since Previous Reporting Period: $ Probate Rule 17(e) AS 13.26.510, .380(b) & 13.06.100 Probate Rule 17(e) AS 13.26.510, .380(b) & 13.06.100 Page 11 of 11 PG-225 (6/17)(cs) CONSERVATOR’S ANNUAL REPORT 15. Trusts. The protected person is a beneficiary of the following trust(s) (meaning the person has the right to receive benef 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 in the last 12 months: 16. Did the protected person help you prepar e (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 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 has been appointed): the following person(s) designated by court order: Conservator’s Signature