Form 4-997. Conservator's inventory.

[For use with Rule 1-140 NMRA] STATE OF NEW MEXICO COUNTY OF _______________ __________________ JUDICIAL DISTRICT In the matter of _______________________________, No. __________ a Protected Person. CONSERVATOR’S INVENTORY Please note: Fill out this net asset summary after you have completed this entire inventory. Use the information that you enter in Sections II and III of this inventory. NET ASSET SUMMARY Total Amount A. Total Assets (SECTION II TOTAL) $ B. Total Debts (SECTION III TOTAL) – $ Net Asset Value (A – B) $ Instructions. You must use this form, Form 4-997 NMRA, when you file a Conservator’s Inventory. The purpose of a Conservator’s Inventory is to give the court as complete a picture as possible of the financial situation of the person under conservatorship, also called the Protected Person. 1. This Conservator’s Inventory is due within ninety (90) days of your appointment as conservator. 2. As conservator you will also be required to complete and file a Conservator’s Report using Form 4-998 NMRA as follows: a. Every year within thirty (30) days after the anniversary date of your appointment. b. Within sixty (60) days after your resignation, removal, or termination as conservator. 3. Please type or print clearly using ink. 4. Complete all sections of this inventory. 5. Attach additional pages if necessary. 6. After completing this inventory, you must sign it under penalty of perjury. 7. Copies of this inventory must be given to the Protected Person, the Protected Person’s guardian if one has been appointed, and any other persons specified by the court. 8. Keep a copy of this inventory for your records. 9. You must keep a copy of ALL of the Protected Person’s financial records for seven (7) years and make them available to the court upon request. SECTION I – Information about the Protected Person. 1. Protected Person’s name: ___________________________________________ 2. Protected Person’s age: _____________________________________________ 3. Protected Person’s physical address: __________________________________ Mailing address (if different): _________________________________________ 4. Protected Person’s telephone number(s) and other contact information: Home: __________________________ Cell: _____________________________ Work: __________________________ Fax: _____________________________ Email: ____________________________________________________________ 5. Has a guardian also been appointed for the Protected Person? [ ] Yes [ ] No If yes, name of guardian ____________________________________________ Address _________________________________________________________ Phone number of guardian __________________________________________ 6. What date were you appointed conservator? ____________________________ 7. Is the Protected Person the beneficiary of a trust? [ ] Yes [ ] No If yes, what is the name of the trust? ___________________________________ What is the current value of the trust? __________________________________ Who is the trustee? ________________________________________________ What is the trustee’s contact information? _______________________________ ________________________________________________________________ Please note: The information you fill out in Sections II through IV below will show the value of the Protected Person’s estate on the date you were appointed. SECTION II – Assets. Please provide information about all of the assets of the Protected Person as of the date of your appointment as conservator. Assets are anything of value owned by the Protected Person. Attach additional pages if necessary. A. Are you holding cash on hand on behalf of the Protected Person? [ ] Yes [ ] No Amount $ ________________ If yes, why is cash kept on hand? _____________________________________ ________________________________________________________________ B. Bank Accounts. Name of Bank/Institution Type of Account (Examples: checking, savings, certificates of deposit, etc.) Value on Date of Appointment $ $ $ TOTAL $ C. Investment Accounts. Name of Bank/Institution Type of Account (Examples: brokerage, investment, money Value on Date of Appointment market, stocks, bonds, IRAs, 401(k) plan, etc.) $ $ $ TOTAL $ D. Life Insurance Policies. Name Of Company Type of Insurance (Examples: whole, term or universal, etc.) Cash Value on Date of Appointment $ $ TOTAL $ E. Real Estate. Address of Property (List all land and buildings) Method for Determining Value (Examples: appraisal, tax assessment, market value, etc.) Value $ $ TOTAL $ F. Vehicles. Make, Model, and Year (List all cars, boats, ATVs, etc.) Value $ $ $ TOTAL $ G. Other Property Not Listed Above. (Attach additional pages if necessary.) Detailed Description of Item or Collection Method for Determining Value (Examples: Value (Only list items or collections that are worth more than $500.00) appraisal, market value) $ $ $ TOTAL $ H. Total value of assets listed above. (The sum of all “Totals” reported in Section II.) SECTION II TOTAL $ Section III – Debts. A. Real Estate Debts. Address of Property and Name of Lender Amount Owed on Date of Appointment $ $ TOTAL $ B. Other Loans. Lender/Creditor Name Purpose of Loan (Examples: automobile loan or personal payday loan, etc.) Amount Owed on Date of Appointment $ $ TOTAL $ C. Credit Cards. Company Name and Address Amount Owed on Date of Appointment $ $ TOTAL $ D. Judgments/Liens. Judgment/Lien Description Amount Owed On Date Of Appointment $ $ TOTAL $ E. Other Liabilities/Debts. Description Amount Owed On Date Of Appointment $ $ $ TOTAL $ F. Total amount of debts listed above. (The sum of all “TOTALS” reported in Section III.) SECTION III TOTAL $ G. Explain any personal or professional relationship between the conservator and any lender/creditor listed in any section above: _________________________________ ___________________________________________________________________ H. Explain any personal or professional relationship between the Protected Person and any lender/creditor listed in any section above: _____________________________ ___________________________________________________________________ SECTION IV – Management of estate. A. What are the Protected Person’s expected sources of income? (e.g., Pension, Social Security, SSI, etc.) ____________________________________________________ ___________________________________________________________________ ___________________________________________________________________ B. What are the Protected Person’s expected expenses? (e.g., housing, care, household, etc.) ______________________________________________________ ___________________________________________________________________ ___________________________________________________________________ C. If expected expenses will exceed expected income, what is your plan to meet the basic needs of the Protected Person? ____________________________________ ___________________________________________________________________ ___________________________________________________________________ D. Do you anticipate significant one-time income over the next 12 months? (e.g., sale of house or car, back payment of social security, insurance proceeds, etc.) [ ] Yes [ ] No If yes, list and describe each income source and amount separately: __________ ________________________________________________________________ ________________________________________________________________ If yes, what do you plan on doing with this income? (e.g., pay off debt, invest) __ ________________________________________________________________ ________________________________________________________________ E. Do you anticipate significant one-time expenses over the next 12 months? (e.g., major home or car repair, medical expenses, gifts) [ ] Yes [ ] No If yes, list and describe the nature and amount of each expense: _______________ ___________________________________________________________________ ___________________________________________________________________ If yes, how do you plan on paying for this expense? __________________________ ___________________________________________________________________ ___________________________________________________________________ F. Are the assets in the estate sufficient to provide for the ongoing care of the Protected Person? [ ] Yes [ ] No If no, describe why and what steps should be taken to provide for the Protected Person: _______________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ ___________________________________________________________________ AFFIRMATION UNDER PENALTY OF PERJURY I, _____________________, am the conservator of _____________________, and I affirm under penalty of perjury under the laws of the State of New Mexico that the information in this report is true and correct. Date Submitted: _____________________________ ___________________________________ Conservator’s Signature ___________________________________ Typed/Printed Name ___________________________________ Street or Post Office Address ___________________________________ City, State and Zip Code ___________________________________ Telephone Number(s) ___________________________________ Fax Number ___________________________________ Email Is this address different from your address in the order of appointment? [ ] Yes [ ] No CERTIFICATE OF SERVICE I certify that on (date) ______________________ I served a copy to the following individuals: [ ] Protected Person _____________________________________ _____________________________________ _____________________________________ _____________________________________ [ ] By mail or other delivery service [ ] By fax (number) _________________ [ ] By hand delivery [ ] By e-mail [ ] Person(s) designated by court order (name and address): _____________________________________ _____________________________________ _____________________________________ _____________________________________ [ ] By mail or other delivery service [ ] By fax (number) _________________ [ ] By hand delivery [ ] By e-mail _____________________________________ _____________________________________ _____________________________________ _____________________________________ [ ] By mail or other delivery service [ ] By fax (number) _________________ [ ] By hand delivery [ ] By e-mail _____________________________________ _____________________________________ _____________________________________ _____________________________________ [ ] By mail or other delivery service [ ] By fax (number) _________________ [ ] By hand delivery [ ] By e-mail _____________________________________ _____________________________________ _____________________________________ _____________________________________ [ ] By mail or other delivery service [ ] By fax (number) _________________ [ ] By hand delivery [ ] By e-mail ________________________________________ Typed/Printed Name ________________________________ Conservator’s Signature