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IN THE CIRCUIT COURT OF COUNTY, WEST VIRGINIA (West Virginia Supreme Court of Appeals)

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BROWSE WEST VIRGINIA SUPREME COURT OF APPEALS (WV) FORMS

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IN THE CIRCUIT COURT OF _______________ COUNTY, WEST VIRGINIA
For Clerk’s Use Only
IN RE: ___________________________________________, AN ALLEGED PROTECTED PERSON
DATE FILED: ____________________________________ CASE NUMBER ___________ - G - __________
STATEMENT OF FINANCIAL RESOURCES
[West Virginia Code: § 44A-2-4]
The Petitioner, in any case where the appointment of a conservator is requested, is required to submit a
reasonably detailed statement of the financial resources of the alleged Protected Person. This form does not need
to be completed or filed if the only relief requested is for the appointment of a guardian. This form must be
completed in its entirety and filed with the Clerk of the Circuit Court prior to the hearing to be held on the
petition to appoint a conservator. The Petitioner should make a reasonable investigation into the Protected
Person's real and personal assets and income, no matter where those assets may be located, and report the findings
in this Statement. Attach additional pages as necessary.
1. ALLEGED PROTECTED PERSON'S SOCIAL SECURITY NUMBER __________ - _____ - ___________
2. TO THE EXTENT KNOWN, WHAT IS THE FAIR MARKET VALUE OF THE PROTECTED
PERSON'S REAL ESTATE OR REAL PROPERTY? [check whether each parcel of real estate is
improved or unimproved and give a brief description of the land (size) and improvements (if any), the
location of the parcel (state, county, district), and the fair market value of the parcel]
PARCEL 1: Improved? __________Yes __________ No. Description: __________________________
______________________________________________________________________________________
______________________________________________________________________________________
Location: ____________________________________________ VALUE $ ________________________
PARCEL 2: Improved? __________Yes __________No. Description:
______________________________________________________________________________________
______________________________________________________________________________________
Location: ____________________________________________ VALUE $ ________________________
[Describe any additional parcels on a separate sheet using the format above, then add the values of all parcels
and enter the total in the space below.]
COMBINED VALUE OF ALL REAL ESTATE VALUE $ ______________________
C CL GC2010 Form 6 / SCA-CG 903 STATEMENT OF FINANCIAL RESOURCES-Page 1 of 3
3. TO THE EXTENT KNOWN, WHAT IS THE APPROXIMATE VALUE OF ALL THE PROTECTED
PERSON'S PERSONAL PROPERTY? [Personal property includes cash on hand or in bank (or other)
accounts, stocks, bonds, furniture, automobiles, jewelry, debts due from others (notes/accounts receivable)
and other assets not considered to be real estate. List each item or classification of personal property]
ITEM(S): _______________________________________________ VALUE $ ______________________
ITEM(S): _______________________________________________ VALUE $ ______________________
ITEM(S): _______________________________________________ VALUE $ ______________________
ITEM(S): ________________________________________________VALUE $ ______________________
ITEM(S): _______________________________________________ VALUE $ ______________________
ITEM(S): _______________________________________________ VALUE $ ______________________
ITEM(S): _______________________________________________ VALUE $ ______________________
ITEM(S): _______________________________________________ VALUE $ ______________________
ITEM(S): _______________________________________________ VALUE $ ______________________
[Describe any additional personal property on a separate sheet using the format above, then add the values of
all the listed items and enter the total in the space below.]
COMBINED VALUE OF ALL ITEMS OF PERSONAL PROPERTY VALUE $ ___________________
4. TO THE EXTENT KNOWN, WHAT IS THE ANTICIPATED ANNUAL GROSS INCOME OR OTHER RECEIPTS OF
THE PROTECTED PERSON?
[List each source of income and the anticipated annual amount of income from that
source]
SOURCE: _____________________________________ ANNUAL INCOME: $ ______________________
SOURCE: _____________________________________ ANNUAL INCOME: $ ______________________
SOURCE: _____________________________________ ANNUAL INCOME: $ ______________________
[List any additional sources of annual income on a separate sheet using the format above, then add the income
from all sources and enter the total in the space below.]
TOTAL ANNUAL INCOME FROM ALL SOURCES: $ ______________________
C CL GC2010 Form 6 / SCA-CG 903 STATEMENT OF FINANCIAL RESOURCES-Page 2 of 3
C CL GC2010 Form 6 / SCA-CG 903 STATEMENT OF FINANCIAL RESOURCES-Page 3 of 3
5. SUMMARY OF ASSETS & ANNUAL INCOME
COMBINED VALUE OF ALL REAL ESTATE (Question 2 total) $ ____________________
COMBINED VALUE OF ALL ITEMS OF PERSONAL PROPERTY (Question 3 total)
+ $ __________________
TOTAL ALL ASSETS (Real Property + Personal Property) $ __________________
TOTAL ANNUAL INCOME FROM ALL SOURCES $ __________________
I, ____________________________________, the Petitioner in the foregoing matter, hereby certify that I
have conducted a reasonable investigation into the assets and income of the alleged protected person named in
this Statement, that the foregoing Statement of Financial Resources is true, complete and correct to the best of my
knowledge, information and belief, that I have included within the foregoing Statement, and any and all
attachments thereto, all items of real property, personal property and all sources of income of the alleged
protected person which are known, or have been disclosed, to me.
Given under my hand this ________ day of _______________________[month], _______[year].
________________________________________________
PETITIONER’S SIGNATURE
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IN THE CIRCUIT COURT OF COUNTY, WEST VIRGINIA (West Virginia Supreme Court of Appeals)

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Completed 25 July 2020

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