Free GN-3500 - Wisconsin

For Official Use

STATE OF WISCONSIN, CIRCUIT COURT, Amended IN THE MATTER OF

COUNTY

Account of Guardian or Conservator
Annual Case No.
Date of Birth

Interim

Final

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 1. 2. 3. 4. 5.

Summary Explanation Beginning Balance. Do not change this amount.
(Inventory net value or ending balance from prior account.)

Total $ $ $ (Subtract) $ $

Total of newly discovered assets and income received during this period. (Add)
(Attach Schedule A- Assets and Income Received.)

Subtotal Total disbursements, distributions and losses incurred. Ending Balance (Total Assets on Hand) at end of accounting period.
(List details in Schedule C ­ Assets on Hand.) Beginning Balance for next Account

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

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

Subscribed and sworn to before me on

Notary Public/Court Official

Notary Public/Court Official

My commission expires:

My commission expires:

Name of Attorney

Telephone Number

Bar Number

Address

GN-3500, 10/06 Account of Guardian/Conservator Page 1 of 3

§§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.

GN-3500 Account of Guardian/Conservator Page 2 of 3

Case No.

(If the space given is insufficient for any item, attach additional sheets.) Schedule A ­ Assets and Income Received 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.)

See attached. Amount

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

$

Schedule B ­ Disbursements, Distributions and Realized Capital Losses 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.)

See attached. Amount

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

$

GN-3500, 10/06 Account of Guardian/Conservator Page 2 of 3

§§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.

GN-3500 Account of Guardian/Conservator Page 3 of 3 Schedule C ­ Assets on Hand (at end of accounting period)

Case No. See attached. Amount

Cash, Checking Accounts, Savings Accounts, Certificates of Deposit (Including Names and Account Numbers) (List balance at end of accounting period.)

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

Amount

Real Estate (Including Encumbrances) (List inventory value, or purchase price if acquired after the initial inventory.)

Amount

Other Assets (Including Burial Trusts) (List inventory value, or purchase price if acquired after the initial inventory.)

Amount

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 Page 3 of 3

§§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.