Initial Report of Guardian

SUPREME COURT OF THE STATE OF NEW YORK RICHMOND COUNTY In the Matter of the INITIAL REPORT ofIndex # INITIAL REPORT OFAs Guardian ForGUARDIAN MHL 24781.30Court Examiner: An Incapacitated Person. I, , residing at , New York , and with telephone number , as Guardian for the above named Incapacitated Person, do hereby make, render and file the following Initial Report of Guardian as follows:1.That the Guardian was appointed by Order & Judgment of this Court onthe day of , 20.That the Guardian has successfully completed all educationalrequirements under 24781.39 of the Mental Hygiene Lawby attending class on the day of ,20, sponsored by (Attach a copy of Certificate issued to Guardian).2.That the Guardian duly qualified as such Guardian by filing, inthe Clerk222s Office of Richmond County, a Bond in the sum of$ with Bonding Company,; BondNumber: , OR bond was waived pursuant to theOrder & Judgment of this Court, and the Commission to Guardian wasissued on , 20.(Attach a copy of the Commission to Guardian).3.That the Guardian has visited the above named IncapacitatedPerson and has taken steps, consistent with the Court Order: American LegalNet, Inc. www.FormsWorkFlow.com DateTimePlace of Visit4.Provisions for Medical, Dental, Mental Health or Related Services:5.Provisions for Social and Personal Services:6.Application of Health and Accident Insurance, as well as GovernmentalBenefits:7.The following is a true and full account of all assets of the Incapacitated Person that have been marshaled by Guardian of the Property: BANK ACCOUNTS: (List names and addresses of Institutions, accountnumbers and amount of money on hand, prior to liquidation by Guardian): NAMEADDRESSACCOUNT # AMOUNT2 American LegalNet, Inc. www.FormsWorkFlow.com STOCKS AND SECURITIES: (List names and addresses of company,number of shares and fair market value of Stock or Security, as of thedate of appointment)# OF FAIR MARKET NAMEADDRESSSHARES VALUE REAL ESTATE: (List property address, description of property, approxi-mate value, names of tenants, if any, rental income collected, if any. Setforth date of filing of Statement identifying real property with the CountyClerk) Address: Description: Approximate Value: Tenants, if any: Rental Income Collected, if any: PERSONAL PROPERTY: (Set forth any Jewelry, Collectibles, Automobiles andCash) INCOME: (Set forth and identify all sources of income the IncapacitatedPerson is entitled to receive) 3 American LegalNet, Inc. www.FormsWorkFlow.com ASSETS NOT YET MARSHALED: (Set forth all Bank Accounts, Stocks,Securities, Security Accounts)Security Bank Accounts StocksSecuritiesAccounts DISBURSEMENTS MADE ON BEHALF OF INCAPACITATED PERSON: CLAIMS AND DEBTS AGAINST THE ESTATE:STATE OF NEW YORK)RICHMOND COUNTY )ss:I, , being duly sworn,depose and say: THAT I am the Guardian for the above named Incapacitated Person;THAT the foregoing Initial Account and Inventory, contain, to the best of myknowledge and belief, a full and true statement of all receipts of the Incapacitated4 American LegalNet, Inc. www.FormsWorkFlow.com Person;THAT all of the money and other personal property of said Incapacitated Person,which have come into my hands, or have been received by any other persons, by myOrder of Authority, or for my use since my appointment, and of the value of theproperty; andTHAT I do not know of any error or omission in the Report to the prejudice ofsaid Incapacitated Person.GuardianSworn to before me this day of , 20.Notary Public 5 American LegalNet, Inc. www.FormsWorkFlow.com