Form 4-998 NMRA Conservator's report. | New Mexico Civil Procedure Rules and Forms

Rule text

[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.

Two Years FINANCIAL SUMMARY Current Last Year Ago Net Asset Value of Previous Year's Report (or Beginning A. $ Inventory if this is your first report) Plus Income (Total from Section B. $ II, below) Less Expenses (Total from C. $ Section III, below) Plus additions or (minus) D. deletions to inventory during the $ year (Minus) additions or plus E. $ deletions to debt during the year Net Asset Value F. $ (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 Amount Amount Amount (Report only the income received by the Received Received Received Protected Person, not your income) this last year two Reporting Years Period 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 Expense Expense Expense two Years ago Type of Expense this one Year (money paid to Reporting ago anyone on behalf of Period the Protected Person or on behalf of his/her legal dependents) 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.

Type of Account (Examples: checking, Value on last Day of Name Of Bank/Institution savings, certificates of Reporting Period deposit, etc.) $ $ $ TOTAL $

C. Investment Accounts.

Type of Account (Examples: brokerage, Value on last Day of Name Of Bank/Institution investment, money Reporting Period market, stocks, bonds, IRAs, 401(k) plan, etc.) $ $ $ TOTAL $

D. Life Insurance Policies.

Type Of Insurance Cash Value on last Name Of Company (Examples: whole, Day of Reporting term or universal, etc.) Period $ $ TOTAL $

E. Real Estate.

Address And Type Of Property Method For Current Market Value (Examples: residential, rental, Determining Value commercial, agricultural, or (Examples: appraisal, mineral interests) tax assessment, market value, etc.) $ $ TOTAL $

F. Vehicles.

Make, Model, and Year Current Market Value (List all cars, boats, ATVs, etc.) $ $ $ TOTAL $

G. Other Property Not Listed Above.

Detailed Description Of Item Or Method For Collection Determining Value Current Market Value (Only list items or collections that (Examples: appraisal, are worth more than $500.00) market value, etc.) $ $ $ $ $ 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. Type of Property (examples: Amount Owed on Address of Property and Name of residential, rental, last Date of Lender commercial, or Reporting Period agricultural) $ $ TOTAL $

B. Other Loans.

Purpose of Loan Amount Owed on (Examples: automobile Lender/Creditor Name last Date of loan or personal payday Reporting Period loan, etc.) $ $ TOTAL $

C. Credit Cards.

Amount Owed on last Company Name and Address Date of Reporting Period $ $ $ TOTAL $

D. Judgments/Liens.

Amount Owed on last Judgment/Lien Description Date of Reporting Period $ $ TOTAL $ E. Other Liabilities/Debts. (promissory notes, IOUs, personal loans, etc.)

Amount Owed on last Description 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

[Approved by Supreme Court Order No. 18-8300-005, effective for all cases on or after July 1, 2018.]

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