Initial Guardianship Inventory - Eleventh Judicial Circuit of Florida

IN THE CIRCUIT COURT OF THE ELEVENTH JUDICIAL CIRCUIT, IN AND FOR MIAMI-DADE COUNTY, FLORIDA, PROBATE DIVISION

Case Number:

Amended Form?

If Yes, version of the Amended Form?

Guardianship Type:

IN RE: THE GUARDIANSHIP OF:

Section:

INITIAL INVENTORY

Guardianship Inception Date:

Report Type:

Ward's Social Security Number:

Guardian Type

Guardian Name:

Name of Representative Payee for Social Security Income:

SUMMARY

1. Net Value of Real Property Assets/Encumbrances: from Section A
2. Cash Assets: from Section B
3. Intangible Assets: from Section C
4. Personal Property: from Section D
5. Total:

Section A. Real Property Assets and Encumbrances

The ward's ownership or liability will be a percentage based upon the total number holding title or responsible for the encumbrance. For example, if three individuals have an ownership interest in the real property, the ward's percentage is 33.3%

To add a record, click (+). To remove, click (-). Note: Attach Copy of Encumbrance Document.

Description and Address

Full Value

How Titled

Ward's %

Ward's Value

1

Description of Property: Street Address:

City:

State:

Zip:

Name of Joint Owner: Street Address:

City:

State:

Zip:

Encumbrance 1

Name of Entity: Account Number: Street Address:

City:

State:

Zip:

Name of Joint Obligor: Street Address:

City:

State:

Zip:

Total for Section A (Total to be transferred to line 1 of Summary Page)

Section B. Cash Assets

The ward's ownership or liability will be a percentage based upon the total number holding title. For example, if three individuals have an ownership interest in the asset, the ward's percentage is 33.3.

To add a record, click (+). To remove, click (-). Note: Attach Copy of Bank Statement.

#

Location

Full Value

How Titled

Ward's %

Ward's Value

1.

Institution Name: Type of Asset: Account Number: Street Address:

City:

State:

Zip:

Name of Joint Owner: Street Address:

City:

State:

Zip:

Total for Section B (Total to be transferred to line 2 of Summary Page)

Section C. Intangible Assets

Account Receivable / Non Business, Annuity, Bonds, Deferred Compensation, IRA, Life Insurance / Cash Surrender, Limited Liability Company, Limited Partnership / SEC, Loans, Money Market / Mutual Fund, Notes, Prepaid College Fund, Retirement Plan, Stocks, Other.

The ward's ownership will be a percentage based upon the total number holding title or responsible for the encumbrance. For example, if two individuals have an ownership interest in the real property, the ward's percentage is 50% The number of shares should only be inserted if the intangible asset is not held in a brokerage or other similar account. If the intangible asset is held in a brokerage or similar account the intangible asset value should be the amount as reflected on the brokerage or similar account statement.

To add a record, click (+). To remove, click (-). Note: Select Type of Intangible Assets from the Drop-down Menu Below.

#

Issuer Name, Address

Full Value

How Titled

Ward's %

Ward's Ending Value

1.

Issuer Name: Type of Asset: Account Number: Number of Shares: Street Address:

City:

State:

Zip:

Name of Joint Owner: Street Address:

City:

State:

Zip:

Total for Section C (Total to be transferred to line 3 of Summary Page)

Section D. Personal Property Assets

The ward's ownership will be a percentage based upon the total number holding title. For example, if three individuals have an ownership interest in the asset, the ward's percentage is 33.3

To add a record, click (+). To remove, click (-).

#

Address and General Description

Full Value

How Titled

Ward's %

Ward's Value

1.

General Description: Type of Asset: Street Address:

City:

State:

Zip:

Name of Joint Owner: Street Address:

City:

State:

Zip:

Total for Section D (Total to be transferred to line 4 of Summary Page)

Section E. Secured/Unsecured Liabilities

Instructions: List all liabilities > $1,000. If debt exceeds $1,000 and is not a part of the monthly budget, please list in this section.

To add a record, click (+). To remove, click (-).

#

Creditor, Description, and Address

Full Amount of Liability

How Titled

Ward's %

Ward's Share of Amount Due

1.

Creditor Name: Account Number: Type of Liability: Description of Security, if any: Street Address:

City:

State:

Zip:

Name of Joint Obligor: Street Address:

City:

State:

Zip:

Section F. Sources of Income

Note: Select Sources of Income from Drop-down Menu

To add a record, click (+). To remove, click (-).

#

Type

Payor

Estimated Annual Amount

1

Section G. Lawsuits Against the Ward

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#

Description of Lawsuit & Court Addresses

Date of Debt Occurrence

Estimated Amount of Claim

1.

Case Number: Plaintiff Name: Describe Cause of Action: Court Name: Court Mailing Address:

City:

State:

Zip:

Section H. Pending Litigation and/or Lawsuits the Ward May Bring if THE COURT'S APPROVAL IS RECEIVED

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#

Description of Lawsuit & Court Addresses

Date of Claim Occurrence

Estimated Amount of Claim

1.

Case Number: Defendant Name: Describe Cause of Action: Attorney Representing Ward: Florida Bar Number: Court Name: Court Mailing Address:

City:

State:

Zip:

Section I. The Ward as of the Guardianship Inception Date was Entitled to Receive, but had not. Received, the Following

Instructions: If the guardian has knowledge of assets which the Ward is entitled to receive, but were not received as of GID then those assets should be listed here. Examples: Insurance Policies, Benefits, Inheritance or settlements from litigation.

To add a record, click (+). To remove, click (-).

#

Description

Estimated Date of Receipt

Estimated Amount

1

Section J. Trusts

Note: Enter Name of Trustee. If Corporate Trustee, select Custodian or Trustee / Successor Trustee

To add a record, click (+). To remove, click (-).

#

Name of Current Trustee, Account, and Addresses

Ward's Interest

Estimated Date Trust was Created

Amount of Trust

1.

Name of Trustee: Financial Institution is: Street Address:

City:

State:

Zip:

Section K. Hazard & Liability Policies, Annuities/Life Insurance/Disability/Long Term Care Policies

To add a record, click (+). To remove, click (-).

Note: If any of the below items listed in Section K is not currently paying benefits, report full value of the same item also in Section C (Intangible Assets). Do not report in Section C if the item is currently paying benefits.

#

Name of Issuer, Address, Account Number

Type of Insured Interest

Status

Description of Insured Interest

1

Name of Issuer: Policy Number: Street Address:

City:

State:

Zip:

CERTIFICATION AND SIGNATURE OF GUARDIAN(S)

(Check all that apply)

A copy of safe-deposit box inventory was provided to the ward.

The ward was declared totally incapacitated.

The ward is a minor.

Proof of the items for Section A is attached.

Proof of the items for Section B is attached.

Proof of the items for Section C is attached.

Proof of the items for Section D is attached.

Proof of the items for Section E is attached.

The ward has a safe deposit box(s) and/or the right to enter a box registered in joint names or in the name of another person or entity.

All property held in a safe deposit box is reflected in the Initial Inventory.

The surety bond as required by the Order Appointing Guardian has been posted.

The required audit fee is attached.

UNDER PENALTIES OF PERJURY, I declare that I have read and examined the foregoing accounting, and the facts alleged are true, to the best of my knowledge and belief.

Guardian Signature

Guardian Name

Date signed by Guardian

Guardian Taxpayer Identification #

Guardian Telephone #

Guardian's Email Address

Guardian Mailing Address

City

State

Zip

Co-Guardian

Co-Guardian Signature

Co-Guardian Name

Date signed by Co-Guardian

Co-Guardian Telephone #

Co-Guardian Taxpayer Identification #

Co-Guardian's Email Address

Co-Guardian Mailing Address

City

State

Zip

CERTIFICATION AND SIGNATURE OF PREPARER

I have prepared the Initial Inventory based upon the information provided by the guardian(s) and/or attorney with no independent verification of the information contained herein. I have not audited or reviewed the Initial Inventory or documents supporting the preparation of the Initial Inventory and, accordingly, do not express an opinion or any other form of assurance as to the accuracy of the information contained in the Initial Inventory.

Preparer Signature

Date Signed by Preparer

Preparer Name

Preparer Taxpayer Identification #

Preparer Telephone #

Preparer's Email Address:

Preparer Mailing Address

Preparer City

State

Zip

CERTIFICATION AND SIGNATURE OF GUARDIAN'S ATTORNEY

The undersigned hereby notifies the Court of the filing of the Initial Inventory of the guardian of the property. This Initial Inventory is the representation of the guardian. I have not audited the accompanying Initial Inventory. The undersigned attorney represents that he/she has examined the contents of this Initial Inventory and that it conforms to the requirements of the Florida Guardianship Law.

Attorney Signature

Date signed by Attorney

Attorney Name

Attorney Florida Bar Number

Attorney Telephone #

Attorney Email Address

Attorney Fax #

Attorney Mailing Address

Attorney City

State

Zip