Fill and Sign the Chancery Division Probate Part Form

ANNUAL REPORT OF GUARDIAN In the Matter of the Annual Report of ,As Guardian for , An Incapacitated Person. Superior Court of New JerseyChancery Division, Probate Part CountyDocket No. This report must be filed by every Guardian once per year unless the Judge otherwise specifies, on the anniversary date of your appointment, which is . The original must be filed with the Surrogate and a copy must also be sent to court-appointed counsel for the ward at the following address: Surrogate: Court-Appointed Counsel: 1. Date of Report 2. Guardian: Please Check: Name: __ guardian of person only Address (include mailing address, if different): __ guardian of property only __ both Telephone No. (Day) (Evening) 3. Incapacitated Person: Name:Address: (If the person lives in a residential facility, include name of the Director or person responsible for care): Telephone No. Revised 12/6/1999, CN 10508-English page 1 of 12 -2- 4. Bond: Bonding company name: Bonding company address:Value of bond (If the bonding requirement was waived, so state): 5. Guardian’s relationship to ward: 1 spouse 2 parent of ward 3 child of ward 4 other relative 5 friend 6 private attorney 7 public guardian or agency 8 other 6. Does the ward live with you? __ Yes __ No If not, how many times do you or your designee visit the ward on an average each month? . On average, how long is the visit (in minutes)? 7. What does the guardian do for the ward? Check all that apply: Manage financial affairs Provide necessities Housekeeping Take on outings Provide transportation Bathe Feed Provide continuous care List any others: IF YOU ARE A GUARDIAN OF THE PERSON, PLEASE COMPLETE THE FOLLOWING QUESTIONS. IF YOU ARE A GUARDIAN OF THE PROPERTY ONLY, PLEASE GO TO QUESTION 19. 8. What is the guardian’s view of the ward’s overall situation, including any significant changes in physical health, intellectual functioning, emotional health and living situation that have occurred over the past year: Revised 12/6/1999, CN 10508-English page 2 of 12 -3- 9. Does the guardian feel that the guardianship should continue? __ Yes __ No Why? 10. Has there been any substantial change in the incapacitated person’s medication? __ Yes __ No If yes, please explain: 11. Examination: Please state the date and place the incapacitated person was last examined or otherwise seen by a physician and the purpose of such visit: Date Physician Purpose Please attach a statement by a physician, psychologist, nurse clinician or social worker, or other person who has evaluated or examined the incapacitated person within three (3) months prior to the filing of this report, regarding an evaluation of the incapacitated person’s condition and current functional level. 12. Residential Setting: Is the current residential setting suitable to the needs of the incapacitated person? __ Yes __ No If no, please explain: Revised 12/6/1999, CN 10508-English page 3 of 12 -4- 13. Treatment: What professional medical treatment, if any, has been given to the incapacitated person during the preceding year? Date Treatment 14.Treatment Plan: Describe the treatment plan for the coming year for the incapacitated person regarding: (a)Medical treatment (b) Dental treatment (c) Mental health treatment (d) Additional related services 15. Social Skills: Please provide information concerning the condition of the incapacitated person’s social skills and needs and the social and personal services used by the incapacitated person. 16. Any changes needed in the guardianship? 17. Has eligibility for such programs as Social Security, Medicare, Medicaid, SSI or Food Stamps ever been checked? __ Yes __No 18. Does the guardian need assistance, whether from the court or from a community agency? Please specify. Revised 12/6/1999, CN 10508-English page 4 of 12 -5- 19.Guardian’s current assessment of ward’s: ( check a rating box for each category) Excellent 1 satisfactory 2 fair 3 poor 4 don’t know 5 Physical health Emotional healthIntellectual functioningLiving situation PROPERTY MANAGEMENT If you have been granted powers regarding the property management of the incapacitated person, please provide the following information, consistent with your order of appointment, pertaining to your fulfillment of your responsibilities to the incapacitated person to provide for property management: 20. Have you identified, traced and collected assets of the incapacitated person since your appointment? __ Yes __ No If no, please explain: 21. Have all of the incapacitated person’s past and current income tax returns and payments been brought up to date? __Yes __ No If no, please explain: 22. Please complete the following schedules and summary. If you have nothing to list on a schedule, state “NONE”. Revised 12/6/1999, CN 10508-English page 5 of 12 SCHEDULE A Assets on Hand at the Beginning of the Accounting Period Please list all assets of the incapacitated person over which you had sole control as guardian as of the beginning of the accounting period. Do not include in this schedule, trust principal in which the incapacitated person has an income interest, property under joint control of any court, or real property not transferred to the guardian. 1. BANK ACCOUNTS AND CASH - please list the name and address of institutions, account numbers and balance deposited in banks or other financial institutions. Please also list any cash on hand not in bank accounts. 2. CORPORATE AND GOVERNMENT SECURITIES ( e.g., CORPORATE STOCKS AND BONDS; FEDERAL, STATE OR MUNICIPAL BONDS AND NOTES) 3. PRESENT OR FUTURE INTERESTS ( e.g., INTERESTS IN PARTNERSHIPS, TRUSTS, LITIGATION SETTLEMENT FUNDS OR PENSIONS) - please list the estimated values of all present and future interests the incapacitated person has in property that has not been transferred to your control. 4. OTHER PERSONAL PROPERTY ( e.g., FURNITURE, JEWELRY, ARTWORK) please list and describe other personal property and indicate estimated value. 5. REAL PROPERTY please describe location and type of real property, type of interest and market value. Revised 12/6/1999, CN 10508-English page 6 of 12 SCHEDULE B Assets Received During Accounting Period Please list all principal assets received during the period of this report (show date received, source and amount or value). Revised 12/6/1999, CN 10508-English page 7 of 12 SCHEDULE C Income Received During Accounting Period Please list all income received during the period from property interests listed in Schedules A and B (show date received, source and amount). Revised 12/6/1999, CN 10508-English page 8 of 12 SCHEDULE D Losses Incurred During Accounting Period Please list all realized losses incurred on principal assets, whether due to sale or liquidation, indicating the asset involved, the date and amount of loss. Revised 12/6/1999, CN 10508-English page 9 of 12 SCHEDULE E Moneys Paid Out During Accounting Period Please list all disbursements, excluding investments, during the period, including date of payment, payee and amount. Revised 12/6/1999, CN 10508-English page 10 of 12 SCHEDULE F Assets on Hand at End of the Accounting Period Please list assets of the type listed in Schedule A on hand at the end of the period and value thereof (see Schedule A for further instructions) 1. BANK ACCOUNTS AND CASH 2. CORPORATION AND GOVERNMENT SECURITIES 3. PRESENT OR FUTURE INTERESTS 4. OTHER PERSONAL PROPERTY 5. REAL PROPERTY Revised 12/6/1999, CN 10508-English page 11 of 12 CERTIFICATION (your name), certifies that I am the Guardian of the within named incapacitated person and that the attached annual report (and schedule(s) (is) (are), to the best of my personal knowledge, complete and true statement of my activities as such Guardian. I am aware that if any of the foregoing are willfully false, I am subject to punishment. Date Guardian Print Name Revised 12/6/1999, CN 10508-English page 12 of 12