Account {MPC 853}

Docket No. ACCOUNT Estate of: Conservatorship of: Other: Commonwealth of Massachusetts The Trial Court Probate and Family Court Division This is the (1st, 2nd, etc.) ANNUAL FINAL ACCOUNT AMENDED FOR THE REPORTING PERIOD FROM (MM/DD/YYYY) TO (MM/DD/YYYY) If Final Account, indicate why: Appointment terminated Estate closed Judicial Order Summarize the financial activity below after completing the detailed accounting information in Schedules A, B and C. Attach additional sheets if necessary. 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 Massachusetts Uniform Probate Code, including the appropriateness of disbursements, the compensation of fiduciaries, attorneys, and others, and the distribution of estate assets. The Court will not review or adjudicate these or other matters unless specifically requested to do so by an interested person, the Personal Representative, or the Conservator. Personal Representative's/Conservator's Information Name: First Name MI Last Name Address (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) SUMMARY OF SCHEDULES (If you are completing this on-line, the totals will auto-fill.) TOTAL SCHEDULE A - Receipts and income: SCHEDULE B - Payment and debts, administration expenses, taxes and distributions: SCHEDULE C - Balance of assets on hand: $ $ $ MPC 853 (3/19/12) ACC American LegalNet, Inc. www.FormsWorkFlow.com page 1 of 5 CONSERVATORSHIPS ONLY Protected Person's Information Name: First Name MI Last Name Age: Current Address: (Include Name of Nursing Facility, if applicable) (Name of Facility if applicable) (Address) (Apt, Unit, No. etc.) (City/Town) (State) (Zip) 1. Is there a continued need for the Conservatorship? Yes No If No, describe why and what steps should be taken. If you would like the Court to take action, you must file the appropriate pleadings with the Court. 2. Are the remaining assets in the estate 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. 3. List the services provided to the protected person. 4. Recommended changes to the Conservator's Plan, if any: The Conservator's Account pursuant to G.L. c. 190B §5-418 must be filed annually and served on all interested persons and on the Protected Person (if over 14) andto any parent or guardian who lives with the Protected Person. All Fiduciaries I state under penalty of perjury that this is a true and complete report of the administration of this estate, during the period shown, both dates inclusive, to the best of my knowledge, information and belief. I understand that this Account is subject to audit and verification. I understand that I am required to maintain supporting documentation for all receipts and disbursements including detailed billing statements from any professional. The Court or any Interested Persons may request copies at any time. Date SIGNATURE OF FIDUCIARY Attorney for Fiduciary: Print Name (Address) (City/Town) (State) (Apt, Unit, No. etc.) (Zip) Primary Phone #: BBO No.: MPC 853 (3/19/12) ACC American LegalNet, Inc. www.FormsWorkFlow.com page 2 of 5 SCHEDULE A- RECEIPTS AND INCOME Is this the first Account filed? Yes No If Yes, use the amounts from the Inventory to complete item 1 in Schedule A below. if No, use the total amount of Schedule C (Book Value) from the prior Account filed to complete item 1 in Schedule A below. Item # Date Description of item received, include name of Payor Balance of Inventory or Prior Account 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. 27. Total Sub-Total Amount Received MPC 853 (3/19/12) ACC American LegalNet, Inc. www.FormsWorkFlow.com page 3 of 5 SCHEDULE B- Payment of Debts, Administration Expenses, Taxes & Distributions Item # 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. 27. Total Date Description of item Paid (include Name of Payee) Sub-Total Amount Paid MPC 853 (3/19/12) ACC American LegalNet, Inc. www.FormsWorkFlow.com page 4 of 5 SCHEDULE C- Balance of Assets on hand at end of accounting period Item # 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. 27. Total Account and Number Name of Financial Institution or Description of Asset Market Value Book Value MPC 853 (3/19/12) ACC American LegalNet, Inc. www.FormsWorkFlow.com page 5 of 5