Form CC 16:2.41 Application for Approval of Monthly Budget of Guardian - Nebraska

Form CC16:2.41 is a Nebraska Judicial Branch form also known as the "Application For Approval Of Monthly Budget Of Guardian". The latest edition of the form was released in December 1, 2016 and is available for digital filing.

Download an up-to-date Form CC16:2.41 in PDF-format down below or look it up on the Nebraska Judicial Branch Forms website.

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Nebraska State Court Form
APPLICATION FOR
REQUIRED
APPROVAL OF MONTHLY
CC 16:2.41 Rev. 12/16
BUDGET OF GUARDIAN
Neb. Ct. R. § 6-1442.01
IN THE COUNTY COURT OF ________________COUNTY, NEBRASKA
IN THE MATTER OF
Case No. ____________________
___________________________
APPLICATION FOR APPROVAL OF MONTHLY BUDGET
Ward/Incapacitated Person
OF GUARDIAN, UPDATED INVENTORY, NOTICE OF
RIGHT TO OBJECT WHEN A HEARING HAS BEEN
SCHEDULED, AND CERTIFICATE OF MAILING
, guardian for the ward/incapacitated person named above, requests that
the court approve a monthly budget including any payments to be made to the guardian as shown below
and that this budget remain in place from year to year until it is changed by the court.
Monthly Income:
Social Security (either retirement or disability)
Supplemental Security income
Support payment of any type (e.g. alimony, child support)
Wages - name of employer is (Fill in name:
)
Other (describe source)
Other (describe source)
Other (describe source)
Total Income
Monthly Expenses:
Rent and utilities paid to guardian
Board (food) paid to guardian
Rent and utilities paid to someone else (Fill in Name:
)
Board (food) paid to someone else (Fill in Name:
)
Transportation expense paid to guardian
Transportation Expense paid to someone else (Fill in Name:
)
Spending money for the ward/incapacitated person
Other (describe payment)
Other (describe payment)
Other (describe payment)
Other (describe payment)
Total Expenses
Page 1 of 9
CC 16:2.41 Rev. 12/16
Application for Approval of Monthly Budget of Guardian
Nebraska State Court Form
APPLICATION FOR
REQUIRED
APPROVAL OF MONTHLY
CC 16:2.41 Rev. 12/16
BUDGET OF GUARDIAN
Neb. Ct. R. § 6-1442.01
IN THE COUNTY COURT OF ________________COUNTY, NEBRASKA
IN THE MATTER OF
Case No. ____________________
___________________________
APPLICATION FOR APPROVAL OF MONTHLY BUDGET
Ward/Incapacitated Person
OF GUARDIAN, UPDATED INVENTORY, NOTICE OF
RIGHT TO OBJECT WHEN A HEARING HAS BEEN
SCHEDULED, AND CERTIFICATE OF MAILING
, guardian for the ward/incapacitated person named above, requests that
the court approve a monthly budget including any payments to be made to the guardian as shown below
and that this budget remain in place from year to year until it is changed by the court.
Monthly Income:
Social Security (either retirement or disability)
Supplemental Security income
Support payment of any type (e.g. alimony, child support)
Wages - name of employer is (Fill in name:
)
Other (describe source)
Other (describe source)
Other (describe source)
Total Income
Monthly Expenses:
Rent and utilities paid to guardian
Board (food) paid to guardian
Rent and utilities paid to someone else (Fill in Name:
)
Board (food) paid to someone else (Fill in Name:
)
Transportation expense paid to guardian
Transportation Expense paid to someone else (Fill in Name:
)
Spending money for the ward/incapacitated person
Other (describe payment)
Other (describe payment)
Other (describe payment)
Other (describe payment)
Total Expenses
Page 1 of 9
CC 16:2.41 Rev. 12/16
Application for Approval of Monthly Budget of Guardian
_____ (Initial if being requested) I request that the court authorize cash withdrawals by the guardian from
ATM’s of up to $________ per month. I request this because (fill in reason)
I acknowledge that I will receive a Notice of Hearing from the court when I file my
Application for Approval of Monthly Budget. After I receive the Notice of Hearing from the
county court, it is my responsibility to send a copy of:
1.
This Application for Approval of Monthly Budget of Guardian;
2.
Notice of Right to Object form; and
3.
Notice of Hearing
to all interested persons no less than 14 days prior to the hearing date.
I must then file with the court a Certificate of Mailing showing I sent this Application for
Approval of Monthly Budget of Guardian, Notice of Right to Object form and the Notice of
Hearing to all interested persons.
Page 2 of 9
CC 16:2.41 Rev.12/16
Application for Approval of Monthly Budget of Guardian
UPDATED INVENTORY
TO THE GUARDIAN: To protect personal information, only the last four digits of the account
should be provided on this form. Complete account information is provided on the Personal and
Financial Information for Guardianships and Conservatorships form.
The inventory listed below is the inventory as of the ending date of this Annual Budget Report,
_____________________.
1. PERSONAL PROPERTY:
Checking Accounts
Bank Name ___________________________
Account no.XXX-_____ _____ _____ _______
$____________________
Bank Name ___________________________
Account no. XXX-_____ _____ _____ ______
$____________________
Bank Name ___________________________
Account no. XXX-_____ _____ _____ ______
$____________________
Savings Accounts
Bank Name ___________________________
Account no.XXX-_____ _____ _____ _______
$____________________
Bank Name ___________________________
Account no. XXX-_____ _____ _____ ______
$____________________
Bank Name ___________________________
Account no. XXX-_____ _____ _____ ______
$____________________
Certificates of Deposit
Bank Name ___________________________
Account no.XXX-_____ _____ _____ _______
$____________________
Bank Name ___________________________
Account no. XXX-_____ _____ _____ ______
$____________________
Bank Name ___________________________
Account no. XXX-_____ _____ _____ ______
$____________________
Stocks and Bonds
$____________________
Vehicles
$____________________
Household goods and furnishings
$____________________
Other: _______________________________
$____________________
TOTAL:
$____________________
Page 3 of 9
CC 16:2.41 Rev. 12/16
Application for Approval of Monthly Budget of Guardian
2. JOINTLY HELD PROPERTY:
With whom ________________________________
$____________________
What ____________________________________
$____________________
With whom ________________________________
$____________________
What ____________________________________
$ ____________________
TOTAL:
$_____________________
3. INCOME (Monthly):
Wages - Employer name:________________________ $_____________________
Social Security
$_____________________
Supplemental Security income
$_____________________
Veterans Administration benefits
$_____________________
Company pension
$_____________________
Interest - From where: ___________________________ $_____________________
Dividends - From where: _________________________ $_____________________
Other: ________________________________________ $_____________________
TOTAL:
$_____________________
4. CREDIT CARD(S) belonging to ward/incapacitated person (If applicable)
Card Name ___________________________
Account no.XXX-_____ _____ _____ _______
$_____________________
Card Name ___________________________
Account no. XXX-_____ _____ _____ _______
$_____________________
TOTAL:
$______________________
5.
REAL PROPERTY (List location by address and value):
Note: legal property descriptions may be obtained from the Register of Deeds in the county that the property
is located. For longer descriptions, reference the location and legal description on a separate page.
Value $________________
Location _____________________________________________
Legal description _______________________________________
_____________________________________________
Value $________________
Location _____________________________________________
Legal description _______________________________________
_____________________________________________
Value $________________
Location _____________________________________________
Legal description _______________________________________
_____________________________________________
Value $________________
Location _____________________________________________
Legal description _______________________________________
$________________
TOTAL:
_____________________________________________
NOTICE: You must file your Letters of Guardianship and/or Conservatorship with the Register of
Deeds in any county where the ward/incapacitated person/protected person has real property or an
interest in real property.
Page 4 of 9
CC 16:2.41 Rev. 12/16
Application for Approval of Monthly Budget of Guardian
I swear or affirm, under the penalties of perjury, that I have examined the above documents, and to the
best of my knowledge and belief, they are true, correct and complete.
Date
Signature(s) of Guardian(s)
Print or Type Name of Guardian(s)
Bar Number and Firm Name (attorneys only)
Street Address/P.O. Box of Guardian(s)
City/State/ZIP Code of Guardian(s)
Phone of Guardian(s)
E-mail Address of Guardian(s)
Page 5 of 9
CC 16:2.41 Rev. 12/16
Application for Approval of Monthly Budget of Guardian

Download Form CC 16:2.41 Application for Approval of Monthly Budget of Guardian - Nebraska

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