New Mexico Forms Library

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. This Conservator’s Report is due as follows: You must complete and file this Conservator’s Report every year within thirty (30) days of the anniversary date of your appointment as conservator. You must complete and file this Conservator’s Report within sixty (60) days of your resignation, removal, or termination as conservator. Please type or print clearly using ink.  Complete all sections of this report. Attach additional pages if necessary. After completing this report, you must sign it under penalty of perjury.  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. Keep a copy of this report for your records. 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?         c Yes            c No

If yes, please check the box that explains why you are filing a Final Report and fill in the requested information.

      c        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: _____________________

___________________________________________________________

___________________________________________________________

c        The court has appointed a new conservator.

Name of new conservator: _____________________________________

Address and phone number of new conservator: ____________________

___________________________________________________________

c        The court has issued an order ending the conservatorship.

c        Other (please explain): ________________________________________

 

SECTION I - Information about the Protected Person.

 

1. Protected Person’s name: ___________________________________________
2. Protected Person’s age: __________
3. Protected Person’s physical address: __________________________________

Mailing address (if different): _________________________________________

4. Protected Person’s telephone number(s) and other contact information:

Home: __________________________ Cell: ____________________________

Work: __________________________  Fax: ____________________________

Email: ___________________________________________________________

5. Has a guardian also been appointed for the Protected Person?

c Yes                        c No

If yes, name of guardian: ____________________________________________

Address: _________________________________________________________

Phone: __________________________________________________________

6. Does the Protected Person have sole control over any money?

c Yes                        c No

If yes, explain: ____________________________________________________

7. Has the Protected Person’s residence changed in the past 12 months?

c Yes                        c No

If yes, explain: ____________________________________________________

________________________________________________________________

________________________________________________________________

8. Describe any significant actions you have taken as conservator regarding the Protected Person’s financial condition during the reporting period.

________________________________________________________________

________________________________________________________________

________________________________________________________________

9. Describe any significant changes of circumstances for the Protected Person (financial, physical or mental health, living arrangements, etc.).

________________________________________________________________

________________________________________________________________

________________________________________________________________

10. Is the Protected Person the beneficiary of a trust?        c Yes            c 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? _______________________________

________________________________________________________________

11. Are the Protected Person’s funds kept in a separate account from the conservator’s funds?

c Yes                        c 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 Reporting Period	Amount Received last year	Amount Received two 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)

 

1. Are you holding cash on hand on behalf of the Protected Person?

c Yes                        c No

If yes, amount $ ________________

If yes, why is cash kept on hand? _____________________________________

 

2. Bank Accounts.

 

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

 

3. 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		$

 

4. Life Insurance Policies.

 

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

 

5. 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		$

 

6. Vehicles.

 

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

 

7. 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		$

 

8. 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)

 

1. 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		$

 

2. Other Loans.

 

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

 

3. Credit Cards.

 

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

 

4. Judgments/Liens.

 

Judgment/Lien Description	Amount Owed on last Date of Reporting Period
	$
	$
TOTAL	$

 

5. Other Liabilities/Debts. (promissory notes, IOUs, personal loans, etc.)

 

Description	Amount owed on Last Date of Reporting Period
	$
	$
	$
TOTAL	$

 

6. Total Amount Owed By Protected Person. (The sum of all “TOTALS” reported in Section V.)           

SECTION V SUM TOTAL

$

 

7. Explain any personal or professional relationship between the conservator and any lender/creditor listed in any section above: ___________________________

________________________________________________________________

________________________________________________________________

8. 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?

c Yes            c No

If yes, please explain: ______________________________________________

________________________________________________________________

B.   Does the conservator charge a fee or receive payment for acting as the Protected Person’s conservator?            

c Yes            c 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?

            c Yes            c 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?

c Yes            c No

If yes, please explain: _________________________________________

___________________________________________________________

___________________________________________________________

3.    Filed for bankruptcy or received protection from creditors?

c Yes            c No

If yes, please explain: _________________________________________

___________________________________________________________

___________________________________________________________

4.    Had any professional or occupational license revoked or suspended?

c Yes            c No

If yes, please explain: _________________________________________

___________________________________________________________

___________________________________________________________

5.    Had the conservator’s driver’s license suspended or revoked?

c Yes            c No

If yes, please explain: _________________________________________

___________________________________________________________

___________________________________________________________

6.    Delegated any powers over the Protected Person to another person?

c Yes            c 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?

c Yes            c No

If yes, please explain: _________________________________________

___________________________________________________________

___________________________________________________________

D.   Is the conservator a court-appointed guardian or conservator for any other person?        

c Yes            c No

If yes, please list the court and case number(s) for each (attach additional pages if necessary): _____________________________________________________

________________________________________________________________

________________________________________________________________

5. If the conservator is required to have a conservator’s bond, is the bond still in place?

c Yes            c 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?            c Yes            c No

 

CERTIFICATE OF SERVICE

           

I certify that on (date) ______________ I served a copy to the following individuals:

 

c  Protected Person             ___________________________             ___________________________             ___________________________             ___________________________   c  Person(s) designated by court order (name and address):             ___________________________             ___________________________             ___________________________             ___________________________                 ___________________________             ___________________________             ___________________________             ___________________________                 ___________________________             ___________________________             ___________________________             ___________________________                 ___________________________             ___________________________             ___________________________             ___________________________

c  By mail or other delivery service c  By fax (number) _____________ c  By hand delivery c  By e-mail     c  By mail or other delivery service c  By fax (number) _____________ c  By hand delivery c  By e-mail   c  By mail or other delivery service c  By fax (number) _____________ c  By hand delivery c  By e-mail     c  By mail or other delivery service c  By fax (number) _____________ c  By hand delivery c  By e-mail   c  By mail or other delivery service c  By fax (number) _____________ c  By hand delivery c  By e-mail

________________________________ Typed/Printed Name

_______________________________ Conservator’s Signature

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