1st Quarter 2011 Report Maryland Attorney General

District Court    Denver Probate Court

County, Colorado

Court Address:

In the Interest of:

Ward COURT USE ONLY

Attorney or Party Without Attorney (Name and Address):

Case Number:

Division   Courtroom

INITIAL REPORT/CARE PLAN       ANNUAL REPORT   

Current Reporting Period From To

(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. When 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 WANTING 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 report (Annual Report ONLY)

Check if Residency is Temporary (Care Plan ONLY)

Name: Age:

Sex:

Street Address:

Mailing Address, if different:

Guardian’s Information: Check if Updated Information from last report

Name: Age: Occupation:

Your Relationship to Ward:

Street Address:

Email Address:

Have you had any criminal charges filed against you or convictions entered since the last report? Yes No

If Yes, explain:

Co-Guardian’s Information (if applicable): Check if updated information from last report

Name: Age:

Occupation: Your Relationship to Ward:

Street Address:

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: Primary Phone: Alternate Phone:

B. If the ward has moved since the last reporting period, identify the date of the move, address of residence, type of residence, and reason for the change.

II. STATUS INFORMATION

A. Do you recommend that the guardianship continue? Yes No

If No, explain:

B. Do you recommend any changes to the guardianship? Yes No

If Yes, explain:

C. Do you wish to remain guardian? Yes No

If No, explain:

Note: If you wish to terminate this guardianship or modify by replacing the current guardian or adding a co-guardian, you must file a separate petition with the Court.

III. CURRENT CONDITION OF THE WARD

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 OTHER ISSUES

A. Has the ward’s physical and medical condition (illness/injuries) changed since the last report? Yes No

If Yes, explain:

B. Has the ward been hospitalized since the last report? Yes No

If Yes, explain:

C. Have there been any medical, social or psychological evaluations of the ward performed? Yes No

Please explain:

D. Is there a need for further medical, social or psychological evaluations of the ward? Yes No

Please explain:

E. Describe the medical, educational, vocational and other services provided to the ward.

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 services 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.

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 Weekly 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?

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 ward’s income? Yes No

If Yes, describe:

C. If applicable, identify the representative 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.

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 PERIOD

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 interested 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.

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 report.

CERTIFICATE OF SERVICE

I certify that on (date), a copy of this was served as follows on each of the following:

*Insert one of the following: hand delivery, first-class mail, certified mail, e-service, or fax.

Signature