Form 4-998. Conservator's report.

[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 REPORT Please note: Fill out this financial summary after you have completed this entire report. Use the information that you enter in Sections II through V of this report and the information from the reports that you filed last year and two years ago. FINANCIAL SUMMARY Current Last Year Two Years Ago A. Net Asset Value of Previous Year’s Report (or Beginning Inventory if this is your first report) $ B. Plus Income (Total from Section II, below) $ C. Less Expenses (Total from Section III, below) $ D. Plus additions or (minus) deletions to inventory during the year $ E. (Minus) additions or plus deletions to debt during the year $ F. Net Asset Value (A + B – C +/– D +/– E) $ Assets (Sum Total from Section IV, below) $ Less Debts (Sum Total from Section V, below) $ Net Asset Value (Line F) $ Instructions. If you were appointed conservator within the past ninety (90) days, do not use this form. The first report that you must file is a Conservator’s Inventory, Form 4-997 NMRA. The Conservator’s Inventory is due within ninety (90) days of your appointment. You must use this form, Form 4-998 NMRA, when you file a Conservator’s Report. The purpose of a Conservator’s Report is to give the court as complete a picture as possible of the current financial situation for the person under conservatorship, also called the Protected Person. 1. This Conservator’s Report is due as follows: a. You must complete and file this Conservator’s Report every year within thirty (30) days of the anniversary date of your appointment as conservator. b. You must complete and file this Conservator’s Report within sixty (60) days of your resignation, removal, or termination as conservator. 2. Please type or print clearly using ink. 3. Complete all sections of this report. 4. Attach additional pages if necessary. 5. After completing this report, you must sign it under penalty of perjury. 6. Copies of this report 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. 7. Keep a copy of this report for your records. 8. 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. REPORTING PERIOD. This report covers the dates beginning _____________________________________________ and ending _____________________________________________. Is this a Final Report? [ ] Yes [ ] No If yes, please check the box that explains why you are filing a Final Report and fill in the requested information. [ ] The Protected Person has died (attach a copy of the death certificate if available). Date and place of death: _______________________________________ ___________________________________________________________ Name of personal representative, if appointed: _____________________ Address: ___________________________________________________ ___________________________________________________________ [ ] The court has appointed a new conservator. Name of new conservator: _____________________________________ Address and phone number of new conservator: ____________________ ___________________________________________________________ [ ] The court has issued an order ending the conservatorship. [ ] Other (please explain): ________________________________________ SECTION I - Information about the Protected Person. A. Protected Person’s name: ___________________________________________ B. Protected Person’s age: ____________________________________________ C. Protected Person’s physical address: __________________________________ Mailing address (if different): _________________________________________ D. Protected Person’s telephone number(s) and other contact information: Home: __________________________ Cell: ____________________________ Work: ___________________________ Fax: ____________________________ Email: _____________________________________________________________ E. Has a guardian also been appointed for the Protected Person? [ ] Yes [ ] No If yes, name of guardian: ____________________________________________ Address: _________________________________________________________ Phone: __________________________________________________________ F. Does the Protected Person have sole control over any money? [ ] Yes [ ] No If yes, explain: ____________________________________________________ G. Has the Protected Person’s residence changed in the past 12 months? [ ] Yes [ ] No If yes, explain: ____________________________________________________ ________________________________________________________________ ________________________________________________________________ H. Describe any significant actions you have taken as conservator regarding the Protected Person’s financial condition during the reporting period. ____________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ I. Describe any significant changes of circumstances for the Protected Person (financial, physical or mental health, living arrangements, etc.). ______________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ J. 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? ______________________________ ________________________________________________________________ K. Are the Protected Person’s funds kept in a separate account from the conservator’s funds? [ ] Yes [ ] No If no, explain: _____________________________________________________ ________________________________________________________________ SECTION II - Income. (Fill in only the boxes that apply to the Protected Person’s income; leave the other boxes blank) Description of each Income Source (Report only the income received by the Protected Person, not your income) Amount Received this Amount Received last year Amount Received two Reporting Period Years ago Social Security Benefits Social Security $ Social Security Disability Insurance (SSDI) $ Supplemental Security Income (SSI) $ Veterans Financial Benefits $ Trust Income $ Wages $ Worker’s Compensation Benefits $ Dividends Received $ Interest Income $ Refunds Tax Refunds $ Insurance Refunds $ Other Refunds (explain) _____________________________________ _____________________________________ $ Realized Gain/Loss on Sale of Asset $ Rental Income $ Royalty Income (oil, gas, etc.) $ Pension or 401(k) Distributions $ Annuity Income $ Alimony or Child Support $ Inheritance and Gifts Received $ Sale of Personal Property Not Listed on Inventory $ IRA Distributions $ Distribution from Tribal or Pueblo Government $ Life Insurance Proceeds $ Other (reverse mortgage, etc.) _____________________________________ _____________________________________ $ SECTION II TOTAL $ SECTION III - Expenses. (Fill in only the boxes that apply to the Protected Person’s expenses; leave the other boxes blank) Description of each Type of Expense (money paid to anyone on behalf of the Protected Person or on behalf of his/her legal dependents) Expense this Reporting Period Expense one Year ago Expense two Years ago Nursing/Assisted Living Home $ In-Home Care $ Rent Payment $ Mortgage Payment Mortgage Interest $ Mortgage Escrow $ Homeowner's Insurance if Not Paid by Escrow Account $ Property Tax if Not Paid by Escrow Account $ Utilities (Gas, Electric, Water, and Sewer) $ Cable/Satellite Television and/or Internet Service $ Cell and other Phone Service $ Transportation (including gasoline expenses) $ Medical, Dental, and Vision Treatment Costs Not Paid by Insurance (including co-pays and deductibles) $ Medical Supplies and Equipment $ Medications Not Paid by Insurance (including co-pays and deductibles) $ Credit Card Payments $ Food, Groceries, Dining $ Clothing $ Recreation, Entertainment, Memberships $ Travel (Vacation, Family Visits, etc.) $ Household Goods and Electronics $ Personal Grooming $ Personal Spending Allowance $ Pet Care (Food, Veterinary Care, Kennel, etc.) $ Income Tax Total Federal Payments $ Total State Payments $ Home/Property Maintenance Costs (including housekeeping and yard service) $ Insurance Auto Insurance $ Medical Insurance $ Life Insurance $ Other Insurance (Long Term Care, Etc.) $ Court Approved Gifts $ Other Gifts or Charitable Donations $ Child/Spousal Support $ Legal Fees $ Fees/Costs Paid to Conservator $ Fees/Costs Paid to Guardian $ Accounting Fees $ Court Costs $ Conservator’s Bond $ Case Management $ Other Expenses (describe) _____________________________________ _____________________________________ $ SECTION III TOTAL $ SECTION IV – Assets. (Fill in only the boxes that apply to the Protected Person’s assets; leave the other boxes blank) A. Are you holding cash on hand on behalf of the Protected Person? [ ] Yes [ ] No If yes, 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 last Day of Reporting Period $ $ $ TOTAL $ C. Investment Accounts. Name Of Bank/Institution Type of Account (Examples: brokerage, investment, money market, stocks, bonds, IRAs, 401(k) plan, etc.) Value on last Day of Reporting Period $ $ $ TOTAL $ D. Life Insurance Policies. Name Of Company Type Of Insurance (Examples: whole, term or universal, etc.) Cash Value on last Day of Reporting Period $ $ TOTAL $ E. Real Estate. Address And Type Of Property (Examples: residential, rental, commercial, agricultural, or mineral interests) Method For Determining Value (Examples: appraisal, tax assessment, market value, etc.) Current Market Value $ $ TOTAL $ F. Vehicles. Make, Model, and Year (List all cars, boats, ATVs, etc.) Current Market Value $ $ $ TOTAL $ G. Other Property Not Listed Above. Detailed Description Of Item Or Collection (Only list items or collections that are worth more than $500.00) Method For Determining Value (Examples: appraisal, market value, etc.) Current Market Value $ $ $ $ $ TOTAL $ H. Total Value Of Assets Listed Above. (The sum of all “TOTALS” reported in Section IV) SECTION IV SUM TOTAL $ SECTION V – Debts. (Fill in only the boxes that apply to the Protected Person’s debts; leave the other boxes blank) A. Real Estate Debts. Address of Property and Name of Lender Type of Property (examples: residential, rental, commercial, or agricultural) Amount Owed on last Date of Reporting Period $ $ TOTAL $ B. Other Loans. Lender/Creditor Name Purpose of Loan (Examples: automobile Amount Owed on last Date of Reporting Period loan or personal payday loan, etc.) $ $ TOTAL $ C. Credit Cards. Company Name and Address Amount Owed on last Date of Reporting Period $ $ $ TOTAL $ D. Judgments/Liens. Judgment/Lien Description Amount Owed on last Date of Reporting Period $ $ TOTAL $ E. Other Liabilities/Debts. (promissory notes, IOUs, personal loans, etc.) Description Amount Owed on last Date of Reporting Period $ $ $ TOTAL $ F. Total Amount Owed By Protected Person. (The sum of all “TOTALS” reported in Section V.) SECTION V SUM 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 VI - Information about the Conservator. For purposes of this section, “conservator” means an individual or a corporate entity appointed by the court, and includes any individual working for a corporate entity who is responsible for the Protected Person. A. Does the conservator have any significant physical or mental health problems that would interfere with the ability to continue as conservator in the next year? [ ] Yes [ ] No If yes, please explain: ______________________________________________ ________________________________________________________________ B. Does the conservator charge a fee or receive payment for acting as the Protected Person’s conservator? [ ] Yes [ ] No If yes, how much has the conservator received since the conservator’s last report? _______________________________________________________________ ________________________________________________________________ How is the conservator’s fee or payment calculated? ______________________ ________________________________________________________________ C. Since the conservator’s last report (or since the conservator’s appointment if this is the conservator’s first report), has the conservator, 1. Been arrested for, charged with, or convicted of any felony or misdemeanor? [ ] Yes [ ] No If yes, please explain: _________________________________________ ___________________________________________________________ ___________________________________________________________ 2. Been investigated by the Children, Youth and Families Department (CYFD), Adult Protective Services (APS), Internal Revenue Service (IRS), or any other governmental agency? [ ] Yes [ ] No If yes, please explain: _________________________________________ ___________________________________________________________ ___________________________________________________________ 3. Filed for bankruptcy or received protection from creditors? [ ] Yes [ ] No If yes, please explain: ________________________________________ ___________________________________________________________ ___________________________________________________________ 4. Had any professional or occupational license revoked or suspended? [ ] Yes [ ] No If yes, please explain: _________________________________________ ___________________________________________________________ ___________________________________________________________ 5. Had the conservator’s driver’s license suspended or revoked? [ ] Yes [ ] No If yes, please explain: _________________________________________ ___________________________________________________________ ___________________________________________________________ 6. Delegated any powers over the Protected Person to another person? [ ] Yes [ ] No If yes, who were power(s) delegate to? ___________________________ What power(s) were delegated? _________________________________ For what period(s) of time? _____________________________________ 7. Received any special training or certification as a conservator? [ ] Yes [ ] No If yes, please explain: _________________________________________ ___________________________________________________________ ___________________________________________________________ D. Is the conservator a court-appointed guardian or conservator for any other person? [ ] Yes [ ] No If yes, please list the court and case number(s) for each (attach additional pages if necessary): ________________________________________________________________ ________________________________________________________________ E. If the conservator is required to have a conservator’s bond, is the bond still in place? [ ] Yes [ ] No If no, please explain: _______________________________________________ ________________________________________________________________ ________________________________________________________________ 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 a change in address from your previous report? [ ] 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