PACKET B—GUARDIANSHIP WITH BUDGET ANNUAL REPORT

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PACKET B—GUARDIANSHIP WITH BUDGETANNUAL REPORTWho may use Packet B? Guardians andConservators for an adult with a court orderedbudget.What are you reporting to the court?Guardian OR Guardian and Conservator: Currentstatus of your adult ward’s health and how youfollowed the court ordered budget.Conservator: How you followed the court orderedbudget.When are the forms to be used? A guardianand/or conservator must file a completed Packet Bwith the court every year. Your first reporting yearends one year after the date the Court entered anOrder appointing you as Guardian and/orConservator. Packet B must be filed within 30 days.The Reporting year ending date and Packet B filingdate will be the same in all following years.For example, if the Order of Appointment wasentered on June 10, 2018, then your first reportingyear begins June 10, 2018 and ends June 9, 2019with your first Packet B due to be filed by July 9,2019. The second reporting year will end June 9,2020 and the second Packet B will be due to befiled by July 9, 2020.What information will be helpful to gather beforecompleting your packet?-Account Statements for each account ownedby the ward for the last month of the reportingyearCheckbook register for the entire year (do notfile the checkbook register with your packet).If this is the first Packet B filing, you will need acopy of the original Order approving Budget.For all following years, you will need to pull outa copy of the last Order approving BudgetList of Interested PersonsThe cost of filing this packet is 5.If you need additional copies of this packet, formsare available on the Supreme Court arings on Packet B : A court hearing will onlybe scheduled if the court has any questions aboutthe budge, if an interested person files an objectionto the budget, If the amount spent in a budgetcategory this reporting year is more than 10%higher or lowerthan identified on the last Order approving Budget,or if the Guardian and/or Conservator files a requestto approve a new budget or a separate Applicationfor Approval of Annual Accounting and/or Fees.Specific Instructions: Packet B : Condition of Ward: If you are also serving as aGuardian answer these questions to provideinformation on the ward’s well-being. Updated Inventory: All Guardians and/orConservators of an adult with a court orderedbudget need to answer the questions, fill inrequested information and provide an accountbalance or value for each financial account(checking, savings, certificate of deposit, investmentaccount, etc. ) as of the last day of the reportingperiod. Budget Report: All Guardians and/orConservators of an adult with a court orderedbudget need to identify:- how much money was spent in eachcategory for the entire year paid to theGuardian and/or Conservator- how much money was spent in eachcategory for the entire year paid to someoneelse (i.e. paid to stores, rental companies,pharmacies, bus companies, the adult, etc.)- whether more or less money is being spentin each category since the last order settingthe budget. Notice of Right to Object: You must completethis form. Certificate of Mailing: This Certificate informsthe court that you have mailed copies of the PacketB to all “interested persons.” List the names andaddresses of the interested persons you sent theforms to on this form. Only mail the completedPacket B to “interested persons” DO NOT mailcopies of bank statements to interested persons. Filing with the Court Pay the filing fee and filethe original completed and signed Packet B with theCourt AND with copies of all financial statements(checking, savings, investment accounts, etc.) forthe last month of the reporting period. All personalinformation should be blacked out along with all butthe last four digits of account numbers.Do not send bank account or financial accountstatements to the interested persons.

Packet WorksheetPlease Note: If you download this annual report from the Judicial Branch website and type in the blanks onthis page, the information will automatically fill in the corresponding blanks on the following pages.It is your responsibility to make sure the information transferred correctly.Is this a conservatorship ONLY?yesno Ward/Protected Person and Case information:Printing the form and handwritingthe answers.Completing the form electronically.Name of ward/protected person:County the case is filed in:Case Number:Annual reporting period: toInterested persons (Include government agency paying benefits and bonding company, if any):Name:Address:If there are more interested persons than listed above, check the box to the left and include them on aseparate sheet of paper. – Note – You will file the separate sheet with the additional names and addresseswith the court when you file the certificate of mailing form.Guardian and/or Conservator information:Name of Gdn/Cons:Street Address/P.O. Box of Gdn/Cons:City/State/ZIP Code:Telephone Number: Email address:If this is being completed by an attorney, Bar Number and Firm Name:Co-Gdn/Cons: information:Is there more than one guardian and/or conservator?yesno Name of Co-Gdn/Cons:Street Address/P.O. Box of Co-Gdn/Cons:City/State/ZIP Code:Telephone Number: Email address:Bar Number and Firm Name (Attorneys only):The following reports were waived by order of the court:Annual report of guardian on condition of wardDate waivedUpdated InventoryDate waivedBudget ReportDate waived

Nebraska State Court FormREQUIREDCC 16:2.34 Rev. 04/2020GUARDIANSHIP WITHBUDGET ANNUALREPORTING FORMSPACKET BIN THE COUNTY COURT OF COUNTY, NEBRASKACase No.IN THE MATTER OF,WardANNUAL REPORT OF GUARDIAN ONCONDITION OF WARDI, the undersigned, am the guardian of the above named ward. My annual report to the courtis as follows:1.As guardian, I believe this guardianship should remain in place.Please explain:YesNo.2.Current physical address of the ward:3.The ward’s residence is:apartment/independent living/own homeguardian’s homenursing home/skilled care facility/assisted livingboarding/extended family homeother:4.The ward has lived in his or her current residence sinceIf the ward has moved within past year, state reasons for change:5.How often do you visit the ward?DailyWeeklyMonthlyOther (describe)6.Are you the care provider?YesNo.If you are not the care provider, how often do you contact the ward’s care provider?DailyWeeklyMonthlyOther (describe)Page 1 of 9Annual Packet BCC 16:2.34 Rev. 04/2020ANNUAL REPORTING PACKET “B”.

7.During the past year, has the ward’s mental health changed?YesNo.If yes, describe:8.During the past year, has the ward’s physical health changed?YesNo.If yes, describe:9.During the past year, the ward has been treated or evaluated by the sionalPhysicianName of ProfessionalDate of last visitPsychiatrist/PsychologistSocial or other case workerOtherOtherDoes the ward participate in decision making?YesNo. If yes, briefly describe:11.As guardian, in your opinion are the ward’s needs being met in their current living arrangements?YesNo.If no, please explain:Page 2 of 9Annual Packet BCC 16:2.34 Rev. 04/2020ANNUAL REPORTING PACKET “B”

UPDATED INVENTORYTO THE GUARDIAN AND/OR CONSERVATOR: To protect personal information, only thelast four digits of the account number should be provided on this form.The Inventory listed below is as of the ending date of this Annual Report, .Are there any changes to any of the accounts identified on your last filed Personal and Financial Information Form? (Check theappropriate box)YesNo.If the answer is “Yes”, you must complete an Updated Financial Information form(CC 16:2.40) and file it with this form.DO NOT SEND THE UPDATED FINANCIAL INFORMATION FORM TO THE INTERESTED PARTIES.Title on AccountType of Account(please check one)Last 4digits ofaccountnumberBalance as ofReportingEnding Date(listed above)checkingsavingscertificate of deposityesnoyesno checkingsavingscertificate of deposityesnoyesno checkingsavingscertificate of depositcheckingsavingscertificate of depositcheckingsavingscertificate of gscertificate of noyesnoyesnoyesnocheckingsavingscertificate of depositcheckingsavingscertificate of depositcheckingsavingscertificate of depositcheckingsavingscertificate of depositcheckingsavingscertificate of depositTOTAL : Page 3 of 9Annual Packet BCC 16:2.34 Rev. 04/2020NewAccount?FinancialInstitutionNameDebit Card?1. PERSONAL PROPERTY:ANNUAL REPORTING PACKET “B”

1. PERSONAL PROPERTY (Continued):TYPE OF PROPERTYPRESENT VALUEStocks, Bonds and Other Securities (Attach List of Brokerage Firms)VehiclesHousehold goods and furnishingsOther:TOTAL : 2. JOINTLY HELD PROPERTY:TYPE OF PROPERTYWITH WHOMTOTAL:PRESENT VALUE 3. Does the ward/minor ward/protected person own or have an interest in Real Property?YesNo. If yes, complete below:REAL PROPERTY (List location by address and value):Note: legal property descriptions may be obtained from the Register of Deeds in the county that theproperty is located. For longer descriptions, reference the location and legal description on a separatepage.LOCATION/ADDRESSLEGAL DESCRIPTIONVALUENOTICE: You must file your Letters of Guardianship and/or Conservatorship with the Registerof Deeds in any county where the ward/minor ward/protected person has real property or aninterest in real property.Have the Letters of Guardianship and/or Conservatorship been filed with the Register of Deedsin each county where each parcel is located? YesNoPage 4 of 9Annual Packet BCC 16:2.34 Rev. 04/2020ANNUAL REPORTING PACKET “B”

4. INCOME (Monthly):SOURCE OF INCOMEMONTHLY AMOUNTWages - Employer name:Social SecuritySupplemental Security incomeVeterans Administration benefitsPension/AnnuityInterest IncomeDividend IncomeOther:Other:TOTAL: 5. Are there any credit cards or other debt of the ward’s/minor ward’s/protected person's name?No. If yes, complete below:YesCREDIT CARD(S) of the ward/minor ward/protected person (If applicable)FinancialInstitution NameName on the CardLast 4digits ofaccountnumberBalance as of LastStatement OTHER DEBT of the ward/minor ward/protected person (If applicable)FinancialInstitution NameDescriptionPage 5 of 9Annual Packet BCC 16:2.34 Rev. 04/2020ANNUAL REPORTING PACKET “B”Last 4digits ofaccountnumberBalance as of LastStatement

BUDGET REPORTI have filed with this Annual Budget Report a copy of the bank statement and/or brokerage statementthat includes the ending date and I have blacked out all but the last four digits of bank accountnumbers and social security numbers on the bank statement and/or brokerage statement.During the reporting year, I have spent the following amounts in categories listed below:DescriptionTotal for 12 month reporting periodCategoryHousing (Rent, Utilities)FoodClothingMedical and DentalSpending money for the ward/minor wardTransportationOther (describe payment)Total ExpensesAmount Paid toAmount Paid toGuardian/Conservator Someone ElseSince the order setting the budget, has there been any change in monthly expenses that hasn’t beenreported previously?NoYes -- describePage 6 of 9Annual Packet BCC 16:2.34 Rev. 04/2020ANNUAL REPORTING PACKET “B”

I swear or affirm, under the penalties of perjury, that I have examined the Annual Report of Guardianon Condition of Ward, Updated Inventory, and Budget Report, and to the best of my knowledge andbelief, they are true, correct and complete.DateSignature of Guardian/ConservatorPrint or Type Name of Guardian/ConservatorStreet Address/P.O. Box of Guardian/ConservatorBar Number and Firm Name (attorneys only)City/State/ZIP Code of Guardian/ConservatorPhoneEmail AddressIs there more than one guardian and/or conservator?Page 7 of 9Annual Packet BCC 16:2.34 Rev. 04/2020yesno ANNUAL REPORTING PACKET “B”

WardCounty CourtCase No.NOTICE OF RIGHT TO OBJECTThe following documents have been filed in the above referenced case:Annual Report;Other(if any):If you object to the contents or accuracy of these filings, you may file an objection and request ahearing before the court. You have 10 days from the date these documents were filed with the court tocomplete and file the Objection form which can be obtained on the Nebraska Supreme Court fault/files/CC-16-2-17.pdf.DateSignature of Guardian/ConservatorPrint or Type Name of Guardian/ConservatorStreet Address/P.O. Box of Guardian/ConservatorBar Number and Firm Name (attorneys only)City/State/ZIP Code of Guardian/ConservatorPhoneEmail AddressIs there more than one guardian and/or conservator?Page 8 of 9Annual Packet BCC 16:2.34 Rev. 04/2020yesno ANNUAL REPORTING PACKET “B”

WardCounty CourtCase No.CERTIFICATE OF MAILINGI,,swear or affirm, under the penalties of perjury, that copies ofthe forms listed below were mailed to all interested persons (including government agencies providingbenefits) and bonding company, if any, at the addresses set forth below on:Annual Report;Other(if any):NAMEADDRESSSee attached (more names and addresses than above)DateSignature of Guardian/Conservator or their attorneyPrint or Type Name of Guardian/Conservator or their attorneyStreet Address/P.O. Box of Guardian/Conservator or their attorneyBar Number and Firm Name (attorneys only)City/State/ZIP Code of Guardian or their attorneyPhoneEmail AddressIs there more than one guardian and/or conservator?yesno Page 9 of 9Annual Packet BCC 16:2.34 Rev. 04/2020ANNUAL REPORTING PACKET “B”

Conservator. Packet B must be filed within 30 days. The Reporting year ending date and Packet B filing date will be the same in all following years. For example, if the Order of Appointment was entered on June 10, 2018, then your first reporting year begins June 10, 2018 and ends June 9, 2019 with your first Packet B due to be filed by July 9 .

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This matter camebefore the Court on a Petition to Transfer Guardianship. The Court finds that the Petition to Transfer Guardianship was provisionally granted and a Provisional Order to Transfer Guardianship was filed in this case. The Court further finds that a Provisio Order nal to Accept Transfer of Guardianship hasbeen filed in the other State.

GUARDIANSHIP ANNUAL REPORTING FORMS PACKET A. CC 16:2.33 Rev. 04/2020. Case No. _ ANNUAL REPORTING PACKET "A" Page . 1. of . 9. Annual Packet A CC 16:2.33 Rev. 04/2020. IN THE MATTER OF , Ward . ANNUAL REPORT OF GUARDIAN ON CONDITION OF WARD . I, the undersigned, am the guardian of the above named ward. My annual report to the court is .

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