New Mexico Forms Library

4-997.  Conservator’s inventory.

[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 INVENTORY

 

Please note: Fill out this net asset summary after you have completed this entire inventory. Use the information that you enter in Sections II and III of this inventory.

 

NET ASSET SUMMARY	Total Amount
A.        Total Assets (SECTION II TOTAL)	$
B.        Total Debts (SECTION III TOTAL)	– $
Net Asset Value (A – B)	$

Instructions.   You must use this form, Form 4-997 NMRA, when you file a Conservator’s Inventory. The purpose of a Conservator’s Inventory is to give the court as complete a picture as possible of the financial situation of the person under conservatorship, also called the Protected Person. This Conservator’s Inventory is due within ninety (90) days of your appointment as conservator. As conservator you will also be required to complete and file a Conservator’s Report using Form 4-998 NMRA as follows: Every year within thirty (30) days after the anniversary date of your appointment.  Within sixty (60) days after your resignation, removal, or termination as conservator. Please type or print clearly using ink.  Complete all sections of this inventory. Attach additional pages if necessary. After completing this inventory, you must sign it under penalty of perjury. Copies of this inventory 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 inventory 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.

 

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 number of guardian __________________________________________

6. What date were you appointed conservator? ____________________________
7. 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? _______________________________

________________________________________________________________

 

Please note: The information you fill out in Sections II through IV below will show the value of the Protected Person’s estate on the date you were appointed.

 

SECTION II – Assets.

Please provide information about all of the assets of the Protected Person as of the date of your appointment as conservator. Assets are anything of value owned by the Protected Person. Attach additional pages if necessary.

 

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

c Yes                        c No              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 Date of Appointment
		$
		$
		$
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 Date of Appointment
		$
		$
TOTAL		$

 

4. Life Insurance Policies.

 

Name Of Company	Type of Insurance (Examples: whole, term or universal, etc.)	Cash Value on Date of Appointment
		$
		$
TOTAL		$

5. Real Estate.

 

Address of Property (List all land and buildings)	Method for Determining Value (Examples: appraisal, tax assessment, market value, etc.)	Value
		$
		$
TOTAL		$

 

6. Vehicles.

 

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

 

7. Other Property Not Listed Above. (Attach additional pages if necessary.)

 

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)	Value
		$
		$
		$
TOTAL		$

 

8. Total value of assets listed above. (The sum of all “Totals” reported in Section II.)

 

SECTION II TOTAL

$

 

Section III – Debts.

 

1. Real Estate Debts.

 

Address of Property and Name of Lender	Amount Owed on Date of Appointment
	$
	$
TOTAL	$

 

2. Other Loans.

 

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

 

3. Credit Cards.

 

Company Name and Address	Amount Owed on Date of Appointment
	$
	$
	$
TOTAL	$

 

 

4. Judgments/Liens.

 

Judgment/Lien Description	Amount Owed On Date Of Appointment
	$
	$
TOTAL	$

 

5. Other Liabilities/Debts.

 

Description	Amount Owed On Date Of Appointment
	$
	$
	$
TOTAL	$

 

6. Total amount of debts listed above. (The sum of all “TOTALS” reported in Section III.)     

 

SECTION III 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 IV – Management of estate.

 

1. What are the Protected Person’s expected sources of income? (e.g., Pension, Social Security, SSI, etc.)

________________________________________________________________

________________________________________________________________

________________________________________________________________

2. What are the Protected Person’s expected expenses? (e.g., housing, care, household, etc.)

________________________________________________________________

________________________________________________________________

________________________________________________________________

3. If expected expenses will exceed expected income, what is your plan to meet the basic needs of the Protected Person?

________________________________________________________________

________________________________________________________________

________________________________________________________________

4. Do you anticipate significant one-time income over the next 12 months? (e.g., sale of house or car, back payment of social security, insurance proceeds, etc.)

c Yes                        c No

If yes, list and describe each income source and amount separately: _________

________________________________________________________________

If yes, what do you plan on doing with this income? (e.g., pay off debt, invest)

________________________________________________________________

________________________________________________________________

5. Do you anticipate significant one-time expenses over the next 12 months? (e.g., major home or car repair, medical expenses, gifts)     c Yes                        c No

If yes, list and describe the nature and amount of each expense: _____________

________________________________________________________________

________________________________________________________________

If yes, how do you plan on paying for this expense? _______________________

________________________________________________________________

________________________________________________________________

Are the assets in the estate sufficient to provide for the ongoing care of the Protected Person?         c Yes                        c No

If no, describe why and what steps should be taken to provide for the Protected Person: __________________________________________________________

________________________________________________________________

________________________________________________________________

 

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 address different from your address in the order of appointment?

            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.]