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Guardians Report And Accounting (Estates Over $80000) 19 - Washington
| Guardians Report And Accounting (Estates Over $80000) Form. This is a Washington form and can be used in Guardianship Superior Court King Local County . |
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON IN AND FOR THE COUNTY OF KING In the Guardianship of: ________________________________, An Incapacitated Person. ) ) ) ) ) ) Case No.: GUARDIAN'S REPORT AND ACCOUNTING (ANR) NOTICE: This Form is to be used if the estate has over $80,000.00 in assets. If you need more room to answer any item, please attach an additional page. 1. Date of Appointment and Reporting Period: The Guardian was appointed on _____________________. This Report covers the period from ___________________ through ___________________. The closing date for all reports is (anniversary date of appointment) _____________________, and the Guardian is required to file reports within 90 days of that date. The Guardian is to file a report every [ months. 2. Continued Certification of Qualifications: The Guardian hereby certifies under penalty of perjury that they are over the age of eighteen, of sound mind, and has never been convicted of a felony or a misdemeanor involving moral turpitude, filed personal bankruptcy or been removed as a fiduciary in any proceeding for cause. (Please explain the circumstances if any you do not meet any of the conditions above.) __________________________________________________________________________ ] 12, [ ] 24, [ ] 36 GUARDIAN'S REPORT AND ACCOUNTING-1 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 __________________________________________________________________________ __________________________________________________________________________ 3. Scope of Guardianship: (Check all boxes that are appropriate.) [ [ [ ] ] ] Full Guardianship of the Person [ ] Full Guardianship of the Estate ] Limited Guardianship of the Estate Limited Guardianship of the Person [ The Incapacitated Person is a beneficiary of a Trust, which was approved by the Court or is subject to court supervision. The Trustee's name, address, and court case no. are: ______________________________________________________. 4. Contact Information for Incapacitated Person, Guardian and Standby Guardian: Incapacitated Person Guardian Standby Guardian Full Name: Mailing Address: City, State & Zip: Telephone Number: Fax Number: Email Address: 5. Interested Parties: (List each person who has filed a Request for Special Notice of Proceedings and those whom the Court has designated to receive copies of reports.) Name Mailing Address Relationship to Incapacitated Person 24 /// 25 /// /// 26 GUARDIAN'S REPORT AND ACCOUNTING-2 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 6. Interested Governmental Agencies: (Check all boxes that are appropriate.) [ ] The Incapacitated Person is a veteran who has served in the United States Military. Notice must be provided to the Department of Veteran Affairs, Henry M. Jackson Federal Building, 915 Second Avenue, Seattle, WA 98174 fifteen days prior to filing this Report with the Court. [ ] The Incapacitated Person is receiving Medicaid long-term funded care from the Department of Social and Health Services. Fees and costs of the guardian or the guardian's attorney are being sought as an adjustment to the Incapacitated Person's amount of participation. Notice must be provided to the Department of Social and Health Services regional administrator of the program that is providing services to the Incapacitated Person ten days prior to filing this Report with the Court. 7. Personal Care Plan: (To be filled out by all Guardians of the Person.) a. Status. The Incapacitated Person is now _____ years of age. [ OR [ ] the Guardian has the following concerns for which a change is requested _______________________________________________________________________. b. Change in Residence. The following changes in residence of the Incapacitated Person occurred during the reporting period: ______________________________. c. Medical Condition. The medical condition of the Incapacitated Person is (list all disabilities and changes that occurred during the report period): __________________________________________________________________. d. Mental Condition. The mental condition of the Incapacitated Person (list diagnosis, if any, and changes that occurred during the report period): __________________________________________________________________. e. Changes in Incapacitated Person's Functional Ability. A description of changes, if any, in the functional abilities of the Incapacitated Person: __________________________________________________________________. ] The Guardian believes that the Incapacitated Person is receiving satisfactory care GUARDIAN'S REPORT AND ACCOUNTING-3 12/2005 REVISEDGUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 f. Activities of the Guardian Taken on Behalf of the Incapacitated Person. The following is a description of the activities in which the Guardian has engaged for the benefit of the Incapacitated Person: ____________________________________. g. Description of Recommended Changes in Scope of Authority of Guardian. The scope of authority of the Guardian [ [ ] remains the same, OR ] should be changed as follows: _______________________________________. following professionals have assisted the Incapacitated Person during the period covered by this report: ______________________________________________. i. Guardian's Plan for Future Care. The Guardian's care plan, [ same, OR [ ] remains the ] is changed as follows: __________________________________. h. Names of Professionals Who Have Aided the Incapacitated Person. The 8. Estate Information:(To be filled out by all Guardians of the Estate. If you serve as Guardian of the person only, you do not have to complete the following section. Please make sure that you have signed where indicated below.) a. Benefits Received. The Guardian receives the following benefits on behalf of the Incapacitated Person: [ ] SSDI/SSA; [ ] SSI; [ ] Medicaid; [ ] Medicare; [ ] Copes; [ ] TANF; [ ] HUD; [ ] Food Stamps; [ ] GAU; [ ] Public Assistance; [ ] VA; [ ] CSA; [ ] Other--Specify: ________________. b. Bond/Blocked Accounts. There is $_______________ in unblocked accounts and $_______________ in blocked financial accounts. The Guardianship bond issued by
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