In the matter of




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STATE OF WISCONSIN, CIRCUIT COURT,       COUNTY

For Official Use



IN THE MATTER OF



     



 Amended
Account of

Guardian/Conservator

 Annual  Interim  Final


     

Date of Birth

Case No.      

I am the Guardian or Conservator of the above named ward or conservatee. I certify that this is an accurate account of the administration of the guardianship or conservatorship for the period from       to      





Line

Summary Explanation

Total

1.

Beginning Balance. Do not change this amount.

(Inventory net value or ending balance from prior account.)

$

     

2.

Total of newly discovered assets and income received during this period. (Add)

(Attach Schedule A- Assets and Income Received.)

$

     

3.

Subtotal

$

     

4.

Total disbursements, distributions and losses incurred. (Subtract)

(List details in Schedule B – Disbursements, Distributions and Realized Capital Losses.)

$

     

5.

Ending Balance (Total Assets on Hand) at end of accounting period.

(List details in Schedule C – Assets on Hand.) Beginning Balance for next Account

$

     


Status of Surety on Bond

The status of the surety upon the guardian or conservator’s bond:

 has not changed.  has changed. Explain:      




Signature of Guardian/Conservator

Signature of Co-Guardian/Conservator


Name Printed or Typed

     



Telephone Number

     

Name Printed or Typed

     


Telephone Number

     

Address

     

Address

     

Subscribed and sworn to before me

on      




Notary Public/Court Official

My commission expires:      



Subscribed and sworn to before me

on      




Notary Public/Court Official

My commission expires:      












Name of Attorney

     


Telephone Number

     


Bar Number

     


Address

     


(If the space given is insufficient for any item, attach additional sheets.)

Schedule A – Assets and Income Received  See attached.

Description

(Example: Social security, pensions, interest, dividends, rental or other income, realized capital gains from assets sold for more than inventory value or purchase price if acquired after the initial inventory, assets discovered after filing initial inventory.)


Amount

     

     


Total: (Enter in Summary on Line 2 on page 1.)

$

     


Schedule B – Disbursements, Distributions and Realized Capital Losses  See attached.

Itemize Disbursements, Distributions and Realized Capital Losses

(Example: Costs of care of the individual; payments made for the benefit of the individual; assets sold for less than inventory value or purchase price if acquired after the initial inventory.)


Amount

     

     

Total: (Enter in Summary on Line 4 on page 1.)

$

     



Schedule C – Assets on Hand (at end of accounting period)  See attached.



Cash, Checking Accounts, Savings Accounts, Certificates of Deposit

(Including Names and Account Numbers)

Amount

(List balance at end of accounting period.)

     


     

Investments

Amount

(List inventory value, or purchase price if acquired after the initial inventory.)

     


     

Real Estate (Including Encumbrances)

Amount

(List inventory value, or purchase price if acquired after the initial inventory.)

     


     

Other Assets (Including Burial Trusts)

Amount

(List inventory value, or purchase price if acquired after the initial inventory.)

     


     

Grand Total: (Enter in Summary on Line 5 on page 1.)

$

     





For Authorized Persons Only
Display of Assets and Examination of Accounts: I am not the guardian or conservator. I am authorized by the court to examine assets. I have examined all securities, depository accounts, and other investments, and such assets correspond with the account, except as indicated.



     

Authorized Signature (Not guardian/conservator)

     

Name Printed or Typed

           

Title Date




GN-3500, 10/06 Account of Guardian/Conservator §§54.19(5), 54.62, 54.66 and 54.76, Wisconsin Statutes

This form shall not be modified. It may be supplemented with additional material.

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