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ADULT CONSERVATORSHIP INVENTORY, ASSET MANAGEMENT PLAN AND RETURN (Fulton County Government)

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ESTATE NO. ________________
ANNUAL REPORT
Ward:
FINAL REPORT
Conservator(s):
PERIOD FROM:
TO:
REAL PROPERTY
(Indicate if property is jointly owned and with whom)
REAL ESTATE PROPERTY ADDRESS OR DESCRIPTION APPROXIMATE EQUITY
Parcel One:
Parcel Two:
Parcel Three:
Parcel Four:
TOTAL APPROXIMATE EQUITY IN REAL ESTATE
INCOME FROM ALL SOURCES
Yearly Total for This Reporting Period Projected Yearly Total for the Next
Reporting Period
Social Security per year
SSI (Supplemental Security Income) per
year
Retirement benefits per year (give
source)
Retirement benefits per year (give
source)
VA benefits per year
Other income per year, including, e.g.,
alimony, annuity, or trust distributions
(give source)
Interest
Dividends
Rent from Investment Properties
Other Income (specify)
TOTAL
Is Social Security income received as representative payee? Yes _____ No _____
ADULT CONSERVATORSHIP
INVENTORY, ASSET MANAGEMENT PLAN AND RETURN
Probate Court
136 Pryor Street
SW, Suite C-230
Atlanta, Georgia, 30303
404-613-4070
ADULT CONSERVATORSHIP
INVENTORY, ASSET MANAGEMENT PLAN AND RETURN
1 Of 8
*****Include a ONE PAGE bank statement for each account showing the balance on
hand on the anniversary date (or as close to the anniversary date as possible). The total
of all checking, savings, money market, certificates of deposit, and other liquid accounts
should equal the net balance on hand shown on page 6.
2.
STOCKS/BONDS/INVESTMENTS (including retirement
and profit-sharing accounts):
a. held by brokers:
If the Ward is a beneficiary of a Trust, please show the name of the Trust, the Trustee, his/her address, telephone number,
and attach an outline showing when and how payments are required to be made under the Trust and the criteria for
payment:
PERSONAL AND INTANGIBLE PROPERTY
(Indicate if property is jointly owned and with whom)
VALUES ON THIS PAGE SHOULD REFLECT BALANCES AS OF THE END OF THE
REPORTING PERIOD.
1. CHECKING/SAVINGS/MONEY MARKET/CERTIFICATES OF DEPOSIT/LIQUID ACCOUNTS:
Bank/Financial Institution/Broker
Account Type
Acct. No.
Joint Owner (if any)
VALUE
TOTAL VALUE OF ACCOUNTS
Brokerage Firm or Institution
Investment
Type
Acct. No. Joint Owner (if any) APPROXIMATE
VALUE
TOTAL APPROXIMATE VALUE OF SECURITIES HELD BY BROKER
Show account statements describing the value of these assets on the anniversary date (or as close to the
anniversary date as possible).
b. privately held:
Company/Issuer No. of Shares Acct. No.
Joint Owner (if any) APPROXIMATE
VALUE
TOTAL APPROXIMATE VALUE OF SECURITIES HELD BY BROKER
Show account statements describing the value of these assets on the anniversary date (or as close to the
anniversary date as possible).
ADULT CONSERVATORSHIP
INVENTORY, ASSET MANAGEMENT PLAN AND RETURN
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3. AUTOMOBILES:
V.I.N. Joint Owner (if any)
APPROXIMATE VALUE
TOTAL APPROXIMATE VALUE OF AUTOMOBILES
4. OTHER ASSETS OF SIGNIFICANT VALUE:
Description
APPROXIMATE VALUE
TOTAL APPROXIMATE VALUE
5. MISCELLANEOUS: List all other non-cash assets in this section.
COMMENTS/EXPLANATIONS ABOUT ANYTHING ON THIS RETURN:
DEBTS AND OTHER LIABILITIES (The ward owes the following debts/liabilities:)
1. Secured debts:
Collateral
Joint Owner (if any)
Approx. Current Balance
TOTAL APPROXIMATE BALANCE OF SECURED DEBTS
2. Unsecured debts:
Account No.
Joint Owner (if any)
Approx. Current Balance
TOTAL APPROXIMATE BALANCE OF UNSECURED DEBTS
TOTAL DEBTS AND OTHER LIABILITIES OF WARD
Current Amount of Bond:
Joint Owner (if any)
ADULT CONSERVATORSHIP
INVENTORY, ASSET MANAGEMENT PLAN AND RETURN
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LIABILITIES AND EXPENSES
This section of the return will give the court an accounting of how funds were spent during the
reporting period covered by this return. You will also give a projected monthly and a projected yearly
approximation of expenses to be incurred during the next reporting period following the one covered by this
return. The Probate Court will use this information to decide whether or not to approve the conservator’s
proposed budget.
Household
Yearly
Expenditures for
Current
Reporting Period
Projected
MONTHLY
Expenditures
Projected
YEARLY
Expenditures
Care Facility
Type of Facility: _______________
Facility:
Rent (Payee):
Mortgage
Company:
Property taxes
Property Insurance
Electricity/Gas
Water/Sewer
Garbage
Telephone
Repairs and Maintenance
Lawn Care/Pest Control
Cable TV
Internet
Groceries
Miscellaneous household
Meals outside home
Total credit account payments
Other monthly debt payments
Other (specify)
Automotive/Transportation
Car Note (Payee):
Gasoline and Oil
Repairs
Tags and license fees
Insurance (Payee):
Bus/train/taxi fares
Disbursements from the reporting period covered by this return MUST be EXACT FIGURES. Approximations
are not acceptable. However, the projected expenses for the next reporting period may be approximations based
on current average monthly expenditures.
ADULT CONSERVATORSHIP
INVENTORY, ASSET MANAGEMENT PLAN AND RETURN
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CONTINUED FROM PREVIOUS PAGE
Yearly
Expenditures for
Current
Reporting Period
Projected
MONTHLY
Expenditures
Projected
YEARLY
Expenditures
Minors or Other Dependents of the Ward
Child Care (Payee):
School Tuition/Supplies/Expenses/Lunches
Clothing/Diapers/Grooming/Hygiene
Medical/Dental/Prescription
Entertainment/Activities
Other Insurance for the Ward
Health Insurance
Payee:
Life Insurance
Payee: ______________________
Date established: ______________
Beneficiary:
Disability Insurance
Payee:
Other (specify)
Ward’s Other Expenses
Dry Cleaning/Laundry
Clothing/grooming/hygiene
Medical/Dental
Prescriptions/medications
Entertainment/Vacations
Publications/Subscriptions/Dues/Clubs
Personal Caretakers/cleaning personnel
Other (specify)
Miscellaneous (specify)
TOTAL EXPENSES
Note: If you are taking commissions, you must attach a separate sheet showing your calculations. However,
you may show the total commissions taken in the Miscellaneous category above.
ADULT CONSERVATORSHIP
INVENTORY, ASSET MANAGEMENT PLAN AND RETURN
5 Of 8
PROJECTED BUDGET SUMMARY
For the next reporting period (period just beginning).
1. Projected Yearly Total Income (From Page 1)
2. Projected Yearly Expenditures (From Page 5)
3. Income Less Total Expenses (positive or negative figure)
Subtract Line 2 From Line 1
YEARLY SUMMARY OF ACTUAL INCOME & EXPENDITURES
For reporting period just ended.
1. Cash Balance from Previous Return
2. Yearly Total of All Income (From Page 1)
3. TOTAL RECEIPTS (Total of Lines 1 and 2)
4. Total Yearly Expenditures for This Reporting Period
(From Page 5, Previous Page)
5. Net Cash Balance on Hand (Subtract Line 4 From Line 3)
The Net Cash Balance on Hand should equal the total
of all checking, savings, money market, certificates of
deposit, and other liquid accounts shown on in Item 1
on Page 2.
Please describe how you plan to manage the ward’s assets, including details regarding sale, refinancing,
reallocation, investments, or other actions, if any:
Is the ward behind in any debt payments? Yes _____ No _____
If yes, please provide the Court the name of the payee(s), nature of the debt(s) and amount(s):
ASSET MANAGEMENT PLAN
ADULT CONSERVATORSHIP
INVENTORY, ASSET MANAGEMENT PLAN AND RETURN
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Sworn to and subscribed before me this
day of _______________, 20
Therefore, based upon the income and expenses shown above, the Conservator(s) hereby request(s)
approval of the proposed budget.
AFFIDAVIT
As Conservator(s) of the above Ward, I/We,__________________________________________,
do swear that the foregoing Return and Inventory and Asset Management Plan contains a just,
true, and complete accounting of the receipts and disbursement incurred in managing the estate
during the just-ended reporting period, as well as an inventory and proposed budget of all property
belonging to said Ward within my/our possession, control, or knowledge.
CERTIFICATE OF MAILING
I/We hereby certify that I/we have mailed a copy of this return by first class mail to the surety on my/
our bond, the ward, and the ward’s guardian, if any.
Signature of Attorney:
Typed/Printed Name:
Address:
Phone:
State Bar Number:
.
Conservator
Notary Public/Clerk of Probate Court Printed Name
Co-Conservator, if any
Notary Public/Clerk of Probate Court Printed Name
Sworn to and subscribed before me this
day of _______________, 20
.
ADULT CONSERVATORSHIP
INVENTORY, ASSET MANAGEMENT PLAN AND RETURN
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IN THE PROBATE COURT OF FULTON COUNTY
STATE OF GEORGIA
IN RE:
______________________________,
WARD
______________________________,
CONSERVATOR(S)
)
)
)
)
)
)
)
ESTATE NO. _____________________
ADULT CONSERVATORSHIP
INVENTORY, ASSET MANAGEMENT
PLAN & RETURN
ORDER
The Conservator filed the above-referenced Annual Return and attached documents and
no objection was filed by any interested party within 30 days of the filing, and the Court has
reviewed the Annual Return and attachments and made no findings of waste of the Ward’s
property or failure to comply with applicable law which warrant a hearing or any further action
by the Court.
Wherefore it is Ordered that the Annual Return with the attached Inventory and Asset
Management Plan shall be filed in the confidential estate file.
It is further Ordered that:
_____ a. The Conservator(s) is/are authorized to disburse from the Ward’s estate the
sum of $____________________ per month for the support of the Ward and the Ward’s
dependents.
_____ b. The Conservator(s) is/are authorized to disburse from the Ward’s estate the
income generated from the corpus of the Ward’s estate for the benefit of the Ward and those
persons who are entitled to be supported by the Ward.
_____ c. The Conservator(s) is/are authorized to disburse from the Ward’s estate the
sum of $____________________ one time during the reporting period for the support of the
Ward and those persons who are entitled to be supported by the Ward.
____ d. Since the expenditures on the proposed annual budget for next year exceed the
expected income and interest earned, the Court approves the type and amounts of
expenditures shown on the budget as being for the benefit of the Ward and the Ward’s
dependents, if any.
It is further Ordered that the Conservator show in the following year’s Annual Return
how such funds actually were spent.
Date
Probate Judge
ADULT CONSERVATORSHIP
INVENTORY, ASSET MANAGEMENT PLAN AND RETURN
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Completed 6 August 2020

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