Fill and Sign the Washington Civil Form

Superior Court of Washington County of In the Guardianship of: _______________________________, Incapacitated Person No. Guardianship Inventory RCW 11.92.040(1) (INV) The [ ] Full [ ] Limited Guardian of the Estate, being first duly sworn, states that the following is a true and correct inventory of the assets and liabilities of the Incapacitated Person as of the date of the Order Appointing the Guardian. A. Assets 1. Real Estate: including the address and its tax assessed value: Address Tax Assess Value [ ] and see attached. 2. Financial Accounts: including the name, address, and phone of the financial institution, type of account, the last four digits of the account number(s) and balance in each account ( for example, savings, checking, money markets, certificate of deposit, retirement accounts, and all investment accounts ): Name of Financial Institution Account Type Account # (last 4 digits only) Balance As of Date Address & Phone Address & Phone [ ] and see attached. Guardianship Inventory (INV) - Page 1 of 4 WPF GDN 04.0500 (01/2009) RCW 11.92.040(1) 3. Stocks, Bonds, and other Securities: ( not held in an account listed above ). Name of Financial Institution Account Type Account # (last 4 digits only) Balance As of Date Address & Phone Address & Phone Address & Phone [ ] and see attached. 4. Personal Property: ( attach itemized list of all items valued at $1,000 or more ). Household Furnishings $ Automobile/Boats $ Other (including items on attached list) $ [ ] and see attached. Total Assets (including attachments) $ ________________ B. Income Description Per Month Wages $ Social Security or SSI $ Veteran’s Benefits $ Pension $ Dividends and Interest $ Other: $ [ ] and see attached. Total Income (including attachments) $_______________ Guardianship Inventory (INV) - Page 2 of 4 WPF GDN 04.0500 (01/2009) RCW 11.92.040(1) C. Liabilities/Debts 1. Mortgages and Liens: name and address of each mortgage or lien holder and the amount owing, the property encumbered and the amount due monthly: Name of Mortgage or Lien Holder Amount Owing Property Encumbered Amount Due Monthly Address Address [ ] and see attached. 2. Installment Loans and Notes: name and address of each loan holder, the amount owing and the amount due monthly: Name of Loan Holder Amount Owing Amount Due Monthly Address Address [ ] and see attached. 3. Credit Cards: name and address of each credit card company and the outstanding balance owing on each and the amount due monthly: Name of Credit Card Company Outstanding Balance Owing Amount Due Monthly Address Address [ ] and see attached. Total Liabilities/Debts (including attachments) $_________________ D. Security for Estate’s Assets 1. Guardian/Trustee’s Bond: [ ] The court does not require a bond. [ ] The court requires a bond in the amount of: $____________ [ ] The bond should: [ ] remain the same OR [ ] be changed to: $____________ Guardianship Inventory (INV) - Page 3 of 4 WPF GDN 04.0500 (01/2009) RCW 11.92.040(1) 2. Total balance in blocked accounts: $___________ 3. Total balance unblocked: $___________ E. Supplemental Information (Optional) _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ ____________________________________________________________________________________________. I certify (or declare) under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. Signed at (city) ____________________ , (state) ___________ on (date) _______________________. ____________________________________ ____________________________ ______________ Signature of Guardian Print Name of Guardian [ ]WSBA [ ]CPG# ___________________________________ ____________________________________________ Address City, State, Zip Code ____________________________________ ____________________________________________ *Telephone/Fax Number Email Address *If you do not want your personal phone number on this public form, you may list your telephone number on a separate form which may be available to parties and the court, as well as its staff and volunteers, but will not be made available to the public. Use Form WPF GDN 03.0100, Guardianship Confidential Information form (Telephone Numbers), for this purpose. Guardianship Inventory (INV) - Page 4 of 4 WPF GDN 04.0500 (01/2009) RCW 11.92.040(1)