SUPREME COURT OF THE STATE OF NEW YORK
COUNTY OF NASSAU
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In the Matter of the Annual Inventory and Account of

 Guardian of the Person and Property of 

An Incapacitated Person.

ANNUAL REPORT OF GUARDIAN

Index No.: 

Annual Report for year of 20__	
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__________________ , residing at _______________________________, telephone no: ____________________as Guardian of the person and property of the above-named incapacitated person, who resides at ___________________________, telephone no: __________, do hereby make, render and file the following report
1.	On _______________, 20___, by Order of this Court, I was appointed Guardian for the person, property or person & property) of ______________________, an Incapacitated Person. I filed my Consent and Designation with the County Clerk. I obtained a bond in the amount of $_________ with__________________ as Surety thereon, Bond No:____________. I received my Commission and it is dated ______________________.  I have continued to act as such Guardian since that date.
2.	The following is a true and full account of all said Guardian's receipts and disbursements for the year 20___

SUMMARY
Schedule A	Principal on hand at date of last accounting:	$________________
Schedule B	   Additional Principal:				$________________
Schedule C	Changes to Principal:	$________________
Schedule D	Income Received:	$________________
Schedule E	Disbursements Paid:				$________________
(Add Schedules A, B, C & D then deduct E):	$________________
Schedule Fl	Balance of cash & securities remaining:	$________________
Schedule F2       Real Estate	$________________
Schedule F3       All other personal property:	$________________
TOTAL ESTATE:							$________________

Schedule A - Principal On Hand on Date of Last Accounting
(List all bank accounts, money markets, IRAs, certificates of deposits, stocks, securities, etc, giving name of bank or institution, account number, amount, shares of stock and market value and inventory value on each account):
				
Bank	Account  #	# of shares	Market Value	Inventory Value	

					

					

					

					

					

					

					

					

					

					

SCHEDULE B – Additional Principal

(List all refunds or reimbursements received, proceeds from the sale of a home, proceeds from the sale of personal property, such as a vehicle, STAR rebates).

Date	Description	Amount Received	

			

			

			

			

			

			

			

			

			

			

Schedule C - Changes to Principal
Detail all accounts opened or closed. Stocks and securities sould include purchases including cost value, stock sales, conversions, name changes, reinvested dividends, stock splits and any other changes to name and/or value. If you abbreviate a stock, please provide a chart showing all abbreviations and use exact same abbreviation when referring to the particular stock throughout report. "Description" refers to whether it was converted, name change, reinvested, split or other changes. IT IS STRONGLY RECOMMENDED THAT YOU OBTAIN A DETAILED 1099 REPORT.

1)	Bank Accounts:
Accounts Opened	Account Closed	Amount	

			

			

2)	Stocks/Securities:

Name of Stock	# of shares	Description	Market Value	Inventory Value	Gain/Loss	

						

						

						

						

Schedule D - Income Received
(List income received from all sources, including but not limited to, social security, pensions, veterans benefits. PLEASE ALSO INCLUDE INTEREST AS REFLECTED ON BANK STATEMENTS)

Source of Income	Amount Received Periodically	Amount Received this Accounting Period	
Sample: Social Security	$500.00 per month	$6,000.00	

			

			

			

			

			

			

			

			

			

SCHEDULE E – Paid Disbursements
Note: 	Please provide copies of cancelled checks, bills paid and/or receipts to support the amount listed. Please detail your disbursements. PLEASE GROUP PAYMENTS BY PAYEE NOT BY DATE OR CHECK NUMBER (i.e., Electric, Medical Insurance, Home Insurance, Home Aids, etc) PLEASE ALSO INCLUDE BANK FEES AS REFLECTED ON BANK STATEMENTS.

Date	Bank Account	Account #	Payee/Description	Amount	

					

					

					

					

					

					

					

					

					

					

SCHEDULE Fl - Balance of Cash/Securities Remaining

Bank/Brokerage Accounts & Securities	# of shares	Inventory Value	Market Value	

				

				

				

				

				

				

				

				

				

				

				

				

SCHEDULE F2 – Real Property
Address	Market Value	Mortgage Amount	Rental Income	If held jointl, with another, list names and relationship to IP	

SCHEDULE F3 – Personal Property

Description	Value	

		

		

		

		

		

ANNUAL REPORT ON THE INCAPACITATED PERSON'S PERSONAL NEEDS:
1.	State the age, date of birth and marital status of the Incapacitated Person.
Age:	
Date of Birth:	
Marital Status:

2.	List and name and present address of the spouse, children and siblings living of the Incapacitated Person.

3.	State the present residence address and telephone number of the Guardian.

4.	State the present residence address and telephone number of the Incapacitated Person. If he or she resides in a facility, provide that information along with the name of the chief executive officer of the facility or the person otherwise responsible for the care of the Incapacitated Person.

5.	State whether there have been any changes in the physical or mental condition of the Incapacitated Person and any substantial changes in medication.

6.	State the date and place the Incapacitated Person was last seen by a physician and the purpose of that visit:

7.	Attach a statement by a physician, psychologist, nurse clinician or social worker or other person who has evaluated or examined the Incapacitated Person within the 3 months prior to the filing of this report, regarding the evaluation of the Incapacitated Person's condition and the current function level of the Incapacitated Person.

8.	Provide a statement of whether the current residential setting is suitable to the current needs of the Incapacitated Person.

9.	Provide a resume of any professional or medical treatment given to the Incapacitated Person during the preceding year.

10.	Describe the plan for medical, dental and mental health treatment and related services for the coming year.

11.	Provide a resume of other information concerning the social condition of the Incapacitated Person, including the social and personal services currently used by the Incapacitated Person, the social skills of the Incapacitated Person and the social needs of the Incapacitated Person.
10.	
STATE OF NEW YORK)
				ss.:
COUNTY OF                  )

____________________, being duly sworn, states:
That I am the appointed Guardian of _______________________ Incapacitated Person.   The foregoing ANNUAL REPORT OF THE GUARDIAN contains, to the best of my knowledge and belief, a full and true statement of all my receipts and disbursements on account of said Incapacitated Person and of all money and other personal property of said person that have come to my hands or have been received by any other person(s) by my order or authority or for my use since my appointment or since the filing of my last annual report, and of the value of all such property, together with a full and true statement and account of the manner in which I have disposed of same and of all property remaining in my hands at the time of the filing of this report; also a full and complete description of the amount and nature of each investment made by me since my appointment or since the filing of my last report.  I do not know of any error or omission in the account and inventory to the prejudice of ___________________, the Incapacitated Person.
______________________________
(Signature of Guardian) 

Sworn to before me
this ________day of __________, 20___

_________________________________
Notary Public