Fill and Sign the 1 Quarter 2011 Reports Maryland Attorney General Form

JDF 850SC R6/1 9 GUARDIAN’S REPORT - ADULT Page 1 of 7  District Court  Denver Probate Court ________________________________ County, Colorado Court Address: I n the Interest of: Ward COURT USE ONLY Attorney or Party W ithout Attorney (Name and Address): Phone Number: E -mail: FAX Number: Atty. Reg. #: Case Number: Division Courtroom GUARDIAN’S REPORT – ADULT  INITIAL REPORT/CARE PLAN  ANNUAL REPORT Current Reporting Period From ________________To __________________ (MM/DD/YYYY) (MM/DD/YYYY) ( REPORTING DATES MUST BE FOR THE PAST YEAR AND MAY NOT REPORT INTO THE FUTURE. ) Instructions to Guardian: Colorado law requires that every guardian of an adult complete a Guardian’s Report every year. W hen answering the questions in this report, you are required to provide details. Answers such as “same as last report/year” and “no change since last report” are not acceptable answers. Your report may be rejected with those answers. COLORADO LAW REQUIRES THAT ANY GUARDIAN W ANTING TO REMOVE THE ADULT FROM THE STATE OF COLORADO MUST OBTAIN COURT PERMISSION. You must file the necessary forms to make this request and obtain Court permission. CONTACT INFORMATION Ward’s Information:  Check if Updated Information from last r eport (Annual Report ONLY)  Check if R esidency is Temporary (Care Plan ONLY) Name: ____________________________________ Age: ___________ Sex:________________ Street Address: (Include Name of Living Center or Nursing Home) City: State: Zip Code: Mailing Address , if different: __________________________________________________________________ City: ____________________________ State: _______________ Zip Code: _______________________ Prim ary P hone: _____________ ________________ Alternate P hone: ___________________________ Guardian’s Information: Check if Updated Information from last r eport Name: ____________________________________________________ Age: _____ ___________ Occupation: _____________________ Your Relationship to W ard: __________________________ Street Address: _________________________________________________ _________ JDF 850SC R6/1 9 GUARDIAN’S REPORT - ADULT Page 2 of 7 City: ___________________ State: ______ Zip Code: _________ Mailing Address , if different : _____________________ _____________________________________________ City: ___________________ State: ___________ Zip Code: _____________________________ Prim ary Phone: _________ Alternate Phone: __ _________ Email Address: ___________________________________________________________ Have you had any criminal charges filed against you or convictions entered since the last report?  Yes  No If Yes, explain: _____________________________________________________________________________ Co-Gua rdian’s Information (if applicable) :  Check if updated information from last r eport Name: ____________________________________________________ Age: ________________ Occupation: _____________________ Your Relationship to Ward: _________________________ Street Address: ______________________________________________________ City: ______________________ State: ____ Zip Code: ________ Mailing Address , if different: _________________________________________________________________ __ City: __________________________ State: __________________ Zip Code: ______________________ Prim ary Phone: _______ Alternate Phone: ____________________ Email Address: ___________________________________________________________ Have you had any criminal charges filed against you or convictions entered since the last report?  Yes  No If Yes, explain: ______________________________________________________________________________ I. PLACEMENT AND CARE SUPERVISION A. Who currently supervises the ward’s care and treatment on a daily basis? Name: ___________________________________ Prim ary Phone: __________________________ Alternate Phone: ______________ B. If the w ard has moved since the last reporting period, identify the date of the move, address of residence, type of residence, and reason for the change. Date of Move Name of Facility and Address Type of Residence Reason for Change II. STATUS INFORMATION Y es No A. Do you recommend that the guardianship continue?   If No , explain: _____________________________________________________________________ _ _________________________________________________________________________________ ______________________________________________________________________ ___________ B. Do you recommend any changes to the guardianship?   If Yes, explain: _____________________________________________________________________ JDF 850SC R6/1 9 GUARDIAN’S REPORT - ADULT Page 3 of 7 _________________________________________________________________________________ ______________________________________________________________________________ ___ C. Do you wish to remain guardian?   If No , explain: ______________________________________________________________________ _________________________________________________________________________________ ___________________________________________________________ ______________________ Note: If you wish to terminate this guardianship or modify by replacing the current g uardian or adding a co -g uardian, you must file a separate p etition with the Court. III. CURRENT CONDITION OF THE WA RD Please describe in detail the current mental condition of the ward: Please describe in detail the current physical condition of the ward: Please describe in detail the current social condition of the ward: IV. PERSONAL CARE AND OT HER ISSUES Yes No A. Has the ward’s physical and medical condition ( illness /injuries)   changed since the last report? If Yes, explain: ________________________________ ______________ ___________________________________________________________________________________ B. Has the ward been hospitalized since the last report?   If Yes, explain: C. Ha ve there been any medical, social or psychological evaluations of the ward performed?   Please explain: _________________________________________________________ _____________ ______________________________________________________________________ _____________ D. Is there a need for further medical, social or psychological evaluations of the ward?   Please explain: _________________________________________________________ _____________ ______________________________________________________________________ _____________ E. Describe the medical, educational, vocational and other services provided to the ward. JDF 850SC R6/1 9 GUARDIAN’S REPORT - ADULT Page 4 of 7 Please describe in detail any medical services provided to the ward: Please list any medications provided to the ward: Please describe in detail any educational services provided to the ward: Please describe in detail any vocational servi ces provided to ward: Please describe in detail any other services provided to ward: F. How often do you contact the ward’s medical provider?  Daily  Weekly  Monthly  Other: How do you contact the ward’s medical provider (phone, email, etc.) ? G. Do you believe the current plan for care, treatment and/or rehabilitation is in the ward’s best interest?  Yes  No If No, describe what changes would be appropriate. H. The ward’s care and living situation is  Very Good  Good  Adequate  Poor I. Describe your plans for the ward’s future care , including any recommended changes. JDF 850SC R6/1 9 GUARDIAN’S REPORT - ADULT Page 5 of 7 V. VISITATION OF WARD Colorado law requires that a guardian maintain sufficient contact with the ward. A. How often do you visit the ward?  Daily  W eekly  Monthly  Other: ______________________ B. How often do you contact the ward or the ward’s care provider?  Daily  Weekly  Monthly  Other: C. When was the last time you saw the ward in person? (date) D. Indicate how long your visits are and summarize your activities with and on behalf of the ward. E. Does the ward participate in decision- making?  Yes  No Briefly describe. VI. FINANCIAL MATTERS A. Are there sufficient financial resources to take care of the ward?  Yes  No If No , what do you believe is the best way to handle this problem? B. Do you have control of the w ard’s income?  Yes  No If Yes, describe: C. If applicable, identify the r epresentative payee for Social Security and other income benefits. Name: ______________________________________ Phone Number:__________________________ D. Have any fees been paid to you in your role as guardian?  Yes  No If Yes, describe: Complete this section only if the guardian has custody of funds. JDF 850SC R6/1 9 GUARDIAN’S REPORT - ADULT Page 6 of 7 E. Have any fees been paid to others for the care of the ward or his/her property?  Yes  No If Yes, describe and identify name of person: Please indicate whether you have possession or control of the following:  Bank Account( s): Name of financial institution(s) and last four numbers of account (s): Estimated Value:  Investment Account(s) : Name of financial institution(s) and last four numbers of account (s): Estimated Value:  Real Estate: Address: Estimated Value:  Personal Property (i.e. jewelry, collectibles , vehicles…) Description: Estimated Value:  Liabilities/Debts: Creditor(s): Estimated Amount: SUMMARY OF FINANCIAL ACTIVITY DURING REPORTING PER IOD Beginning balance of bank accounts (savings, checking, etc.) $ Plus money received ( Social Security, S SI, pension, disability, interest, etc .) from any source on behalf of the Ward +$ Less total fees to care providers -$ Less total monies paid to the W ard, e.g. personal needs -$ Less total fees paid to guardian -$ Less any other expenses, e.g. housing, insurance, maintenance -$ Ending balance of bank accounts $ You are required to maintain supporting documentation for all receipts and all disbursements under your control during the duration of this appointment. The court or any i nterested persons as identified in the Order Appointing Guardian may request copies at any time.  By checking this box, I am acknowledging I am filling in the blanks and not changing anything else on the form.  By checking this box, I am acknowledging that I have made a change to the original content of this form. JDF 850SC R6/1 9 GUARDIAN’S REPORT - ADULT Page 7 of 7 IMPORTANT THIS SECTION MUST BE COMPLETED CORRECTLY AND SIGNED OR THE REPORT MAY BE REJECTED. Colorado Law REQUIRES that the Guardian’s Report be served on the PROTECTED PERSON AND INTERESTED PERSONS pursuant to Order Appointing Guardian, including minors 12 years of age or older (§ 15- 14-309(4), C.R.S.). In the space below, list the names, addresses, and method of delivery for each party listed on the Order Appointing Guardian and provide each party with a copy of this r eport. VERIFICATION I declare under penalty of perjury under the law of Colorado that the foregoing is true and correct. Executed on the ______ day of Executed on the ______ day of (date) (date) _______________________, _________, _______________________, _________, (month) (year) (month) (year) at _____________________________________ at ______________________________________ (city or other location, and state OR country) (city or other location, and st ate OR country) _______________________________ _______________________________ (printed name) (printed name) _______________________________ _______________________________ (Signature of Guardian) (Si gnature of Co- Guardian, if any) ______________________________________ __________________ Attorney Signature, (if any) Date CERTIFICATE OF SERVICE I certify that on ___________________ (date), a copy of this _______________ (name of document) was served as follows on each of the following: Name and Address Relationship to Decedent, Ward, or Protected Person Manner of Service* *Insert one of the following: hand delivery, first -class mail, certified mail, e -service, or fax. _______________________________________________ Signature NOTE: If you wish to change the persons entitled to receive copies of reports or other documents filed, you must file a separate petition with the court.