STATE OF SOUTH CAROLINA	)
)	IN THE PROBATE COURT
COUNTY OF:	)
)	CONSERVATORSHIP ANNUAL ACCOUNTING
IN THE MATTER OF:	)
)	CASE NUMBER:

Conservator:

1.

a.

This is a full and true statement of account in the above matter, which protected person resides at , covering the period from the day of , 20 to the day of , 20 .

b.

I have on file a surety bond approved by the Court in a penal sum of $ with the Company as surety.

2.	Recapitulation of Accounts

Beginning balance of cash

$

Plus money received for all sources (item 3)

+$

TOTAL

$

Less Total money spent (item 4)

-$

TOTAL VALUE OF ESTATE

$

The Conservator represents that this account contains a correct statement of all receipts and disbursements and that its contents are true to the best knowledge and belief of the Conservator.

SWORN to before me this	day of	Signature:
, 20
Name:
Address:
Notary Public for South Carolina	Telephone (O):
My Commission Expires:
(H):

Attach Bank or Brokerage Statements

3.	MONEY RECEIVED
Date
RECEIVED FROM

(List each source separately)

Example: First Bank = Check #11111
Amount
$
$
$
$
$
$
(Attach additional pages, if necessary)

TOTAL brought forward from attached pages

$

TOTAL AMOUNT RECEIVED

$

(Enter under recapitulation, page 1, item #2)

4.	MONEY SPENT
Date
To Whom Paid and Purpose
Amount
$
$
$
$
$
$
(Attach additional pages, if necessary)

SUB-TOTAL brought forward from attached pages

$

TOTAL AMOUNT SPENT

$

(Enter total on Recapitulation, page 1, item #2)

5.	CERTIFICATION OF BALANCE ON DEPOSIT:
NAME AND ADDRESS OF INSTITUTION:
Account Type (i.e., Checking, Savings):

Balance on deposit*

$

*Including interest of $ paid during the period covered by the accounting.
I CERTIFY THAT on the day of , 20 , the last day of the period covered by this accounting, there was on deposit in this institution to the credit of this Fiduciary the following balance:$ .

SIGNATURE AND TITLE OF CERTIFYING BANK

CERTIFICATION OF INVESTMENTS (to be executed by the Clerk of Court, a bank official, an authorized official

of an insurance or investment company, or an authorized official or agent of the corporate surety on fiduciary bond):

Kind of Bond or Security
Interest Rate

Date of Purchase

Face Value

Cost

TOTAL COST

$

I CERTIFY that the securities listed herein were exhibited to me by the Fiduciary as being the property of the protected person and in the custody and control of the Fiduciary.

Date

SIGNATURE AND TITLE OF CERTIFYING OFFICIAL

Form #561PC (2/2004)	Page 2 of 3

Form #561PC (2/2004)	Page 1 of 3

62-5-419

STATE OF SOUTH CAROLINA

2004-02-10

HMcCaw