Accounting of Conservator
Accounting of Conservator
Page 1 of 7 Pages
PLEASE TURN TO THE NEXT PAGE TO BEGIN ACCOUNTING
SCA-CG 915C-1 / 6-94
IN THE CIRCUIT COURT OF _______________ COUNTY, WEST VIRGINIA
For Clerk's Use Only
IN RE: ___________________________________________, A PROTECTED PERSON
DATE FILED: ____________________________________ CASE NUMBER ___________ - G - __________
ACCOUNTING OF CONSERVATOR
[West Virginia Code: §§ 44A-3-9 and 11]
INSTRUCTIONS FOR COMPLETION OF REPORT
A.
This form is a required submission under West Virginia Code: § 44A-3-9. Pursuant to the provisions of
West Virginia Code: § 44A-3-11, the first accounting form must be completed and filed not later than sixty
(60) days following the first anniversary of your appointment as a conservator. You have the option and
may elect to file your accountings on a calendar year basis and the due date for calendar year accountings
is April 15 of the succeeding year. Please note: If you elect to file on a calendar year basis, the accounting
cannot cover a period of more than one (1) year. You are also required to file an accounting at least
annually after the first accounting, unless the Court requires you to file additional accountings, and you
are also required to file an accounting if your appointment as conservator is terminated. This report, and
any subsequent reports, must be filed with the Circuit Court Clerk on or before the due dates above.
B.
All information provided in this accounting must be printed or typed and be clearly readable.
C.
All information requested MUST be provided, if known. If unknown, you must state it is unknown.
D.
Please be sure you read and answer all questions carefully and in as much detail as possible.
E.
Answers to some questions may require more space than provided. If so, attach additional pages as
needed and label each response on such page(s) with the number of the applicable question.
Accounting of Conservator
Page 2 of 7 Pages
Name of Protected Person: ___________________________________________ Court Case Number __________-G-___________
Name of Conservator: _________________________________________ Date of Appointment: ______________________________
This accounting is your [check any applicable category]:
__________ first
accounting
__________
periodic annual accounting
__________
final accounting
__________
other accounting ordered by Court
Date of this accounting: __________________ covering a time period from ___________________ to _________________________
Date of your last accounting [if applicable]: _________________ covering ___________________ to _________________________
PART 1: RECEIPTS. List any and all receipts of income, cash, checks, interest, dividends or other money received during the
reporting period. Include any property received and the fair market value thereof unless you have filed an amended inventory with
the Court which describes the property and value of such property.
DESCRIPTION AND SOURCE OF RECEIPT
AMOUNT
OR
VALUE
TOTAL RECEIPTS. Total of all receipts in this part including any amounts or values on attached pages.
SCA-CG 915C-2 / 6-94
Accounting of Conservator
Page 3 of 7 Pages
PART 2: DISBURSEMENTS or DISTRIBUTIONS. List any and all disbursements or distributions of cash, checks or other
money or property during the reporting period. If property was given, disbursed, or distributed in addition to indicating the payee
and purpose, also indicate the specific item of property given in column 1 and the fair market value of the property in column 2
PAYEE AND PURPOSE OF DISBURSEMENT OR DISTRIBUTION
AMOUNT
OR
VALUE
TOTAL OF ALL DISBURSEMENTS AND/OR DISTRIBUTIONS in this part, including any amounts or
values on attached pages.
SCA-CG 915C-3 / 6-94
Accounting of Conservator
Page 4 of 7 Pages
PART 3: ASSETS OF THE ESTATE. List all known assets of the Estate of the Protected Person and the approximate amount
or fair market value of each item as of the closing date of this accounting.
DESCRIPTION OF ASSET
AMOUNT
OR
VALUE
TOTAL ASSETS. Total of all assets in this part, including any amounts or values on attached pages.
SCA-CG 915C-4 / 6-94
Accounting of Conservator
Page 5 of 7 Pages
PART 4: LIABILITIES OF THE ESTATE. List all known liabilities of the Estate of the Protected Person as of the closing
date of this accounting.
DESCRIPTION OF LIABILITY
AMOUNT
OR
VALUE
TOTAL LIABILITIES. Total of all liabilities in this part, including any amounts or values on attached
pages.
SCA-CG 915C-5 / 6-94
Accounting of Conservator
Page 6 of 7 Pages
PART 5: OTHER INFORMATION. Answer each of the following questions in as much detail as possible.
1.
Describe the services being provided to the Protected Person during the time period covered by this accounting:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
2.
Describe the significant actions taken by the conservator during the time period covered by this accounting:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
3.
What is your recommendation as to the need for continued conservatorship? Explain your response.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
4.
Do you recommend any changes in the scope of the conservatorship? If so, detail the changes recommended and explain the
reasons for recommending such changes.
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
SCA-CG 915C-6 / 6-94
Accounting of Conservator
Page 7 of 7 Pages
5.
In the space below, provide any information requested by the Court but not otherwise requested in this form:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
6.
In the space below, provide any further information which, in your opinion, the Court may find useful in reviewing the case
of the Protected Person:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
7.
Are you requesting compensation for your services as conservator ?
__________ YES
__________ NO
If you responded with "YES," what is the amount of your request:
$ _____________________________
8.
What are the reasonable and necessary expenses you have incurred as conservator
$ _____________________________
[If you listed an amount in this question, attach an itemized listing of your reasonable and necessary expenses.]
STATE OF ___________________________________
COUNTY OF ________________________________, to-wit:
I, ________________________________________________, the conservator named in this accounting, do hereby certify
that the information provided in this ACCOUNTING OF CONSERVATOR is true, correct and complete to the best of my
knowledge, information and belief.
Given under my hand this ________ day of _______________________________, 20 ___________.
_________________________________________________________
CONSERVATOR'S SIGNATURE
The foregoing was taken, subscribed and sworn to before me by the said _________________________________________,
in my said county and state on this, the __________ day of __________________________________, 20_____________.
Given under my hand and NOTARIAL SEAL.
[AFFIX NOTARIAL SEAL]
_________________________________________________________
NOTARY PUBLIC
My Commission Expires:__________________________________.
SCA-CG 915C-7 / 6-94