CIV-693 Instructions for Child's Change of Name

GUARDIANSHIP ANNUAL REPORT

IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT

In the Matter of the Protective Proceedings of:

Name of Ward:

Date of Birth:

Residential location of ward:

CASE NO.

Ward’s Telephone #:

Instructions

Please type or print clearly using black ink. In preparing the report, you must consult with the ward as much as possible. The court will treat the information in this report as confidential.

If you are unable to complete this form without help, you may find assistance on the website of the Office of Public Advocacy (OPA): http://doa.alaska.gov/opa/pg/pub_guard.html. Your local library and court may also have a binder of helpful information entitled “Family Guardian Education Materials,” prepared by the Alaska State Association for Guardianship and Advocacy. You may also call OPA at 269-3500 (in Anchorage), 451-5933 (in Fairbanks) or 1-877-957-3500.

After completing this report, you must sign it under oath (or affirmation) in the presence of a notary public or court clerk. See last page.

If you are a full guardian with the powers of a conservator, you must fill out the entire form. If you are a partial guardian and do not have the powers of a conservator (or if a separate conservator has been appointed), you do not need to fill out the financial information in paragraphs 10 through 16. The purpose of this report is to give the court as complete a picture as possible of the ward’s current situation and what has happened in the last 12 months.

Reporting Period

This report covers the following period: From To

Information About Guardian

Guardian’s Name Daytime Phone

Mailing Address

Check here if this mailing address is new. If you change your address, please notify the court.

Residence Address

Do you live with the ward? Yes No

Relationship to ward:

2. Medical Care.

a. Which of the following medical professionals has the ward seen in the past 12 months?

Medical Doctor

Dentist

Eye Doctor

Ear Doctor

Psychologist or Psychiatrist

Other:

b. Describe any medical problems (physical or mental) the ward has, and describe what is being done or will be done about them:

c. Describe any plans you have to change the care currently being provided for the ward’s medical problems:

d. Have you discussed these medical issues with the ward? Yes No

Explain what the ward wants:

Explain why not:

e. Are there any problems providing medical care or treatment for the ward?

f. Is a no-code (Do Not Resuscitate) provision in place for the ward? Yes No

g. Did the ward execute a durable power of attorney for health care or other advance health care directive? Yes No

If yes, who is the agent authorized to make health care decisions for the ward?

3. School and Job Training.

a. Does the ward attend school or any type of job training? Yes No

Describe studies (include name and location of school):

No, because:

b. Is there any type of education or training that would benefit the ward?

c. Have you discussed this with the ward? Yes No

Explain what the ward wants:

Explain why not:

4. Work.

a. Is the ward employed? No Yes

No, because:

Yes. Describe (include type of work, name of employer, address, phone, and how long employed):

b. If not employed, would it be in the ward’s best interests to obtain employment?

c. Have you discussed this with the ward?

Yes. Explain what the ward wants:

No. Explain why not:

5. Social and Recreational Activities.

a. Describe activities the ward enjoys:

b. Have you been able to help make these activities available to the ward?

c. Do you have any plans concerning additional social and recreational activities for the ward?

6. Contacts with Ward.

a. If the ward does not live with you, how often have you visited the ward in the past 12 months?

b. Have there been any other contacts? No Yes, as follows:

by telephone

by mail or e-mail

through 3rd person

other

7. Decision Making.

a. Have there been any changes in the ward’s ability to make decisions about matters affecting the ward’s health and safety?

b. When a decision has to be made about something for the ward, how are the decisions made?

(1) Describe decisions made by ward alone:

(2) Describe decisions made by guardian alone:

(3) Describe decisions made by guardian and ward together:

8. Community Resources

List the community organizations that are currently involved with the ward.

9. Significant Actions.

Describe any significant actions you have taken as guardian for the ward during the past 12 months:

10. Ward’s Annual Income.

Social Security Benefits - SSA: SSI:

Adult Public Assistance: Veterans Financial Benefits:

Alaska Longevity Bonus: Permanent Fund Dividend:

Native Corporation Dividend: Wages:

Dividends/Interest: Rental Income:

Pension: Annuities:

Other (describe):

Total Annual Income:

Total Annual Income During Previous Reporting Period:

Explain any difference more than $1000:

11. Ward’s Annual Expenses.

Nursing/ Assisted Living Home:

Rent Payment:

Mortgage Payment:

Utilities:

Transportation:

Medical Treatment Costs:

Medications:

Credit Card Payments:

Food:

Clothing:

Recreation or Entertainment:

Personal Expenses (include allowance):

Income Tax & Property Tax:

Home/Property Maintenance Costs:

Home Insurance:

Auto Insurance:

Medical Insurance:

Life Insurance:

Gifts:

Child/Spousal Support:

Fees/Costs Paid to Guardian:

Other (list all other payments made):

Total Annual Expenses:

Total Annual Expenses During Previous Reporting Period:

Explain any difference more than $1000:

12. Money Controlled By Ward.

Does the ward have sole control over any money? Yes No

If yes, please explain:

Is this money included in the income and expenses listed in #10 and #11? Yes No

Explain:

13. Ward’s Assets at the end of this Reporting Period

Date:

a. Cash on hand (not in an account) $

Explain any changes in the last 12 months:

b. Burial Account

Name of Bank or Institution Type of Account Account Number Balance

Explain any changes in the last 12 months:

c. Alaska Native Corporation Dividend Account

Name of Bank or Institution Type of Account Account Number Balance

Explain any changes in the last 12 months:

d. List all other bank accounts, certificates of deposit, etc.

Name of Bank or Institution Name(s) on Account Account Number Balance

Explain any changes in the last 12 months:

e. Brokerage Accounts, Stocks, Bonds, and Other Securities.

Name of Company Name(s) on Account Account Value on

Explain any changes in the last 12 months:

f. Retirement Accounts.

Name of Company Beneficiary Current Value

Explain any changes in the last 12 months:

g. Ward’s Life Insurance Policies.

Name of Company Beneficiary of Life Insurance Face Value Cash Value

Explain any changes in the last 12 months:

h. Real Estate that Ward Owns.

(1) Does ward own a home? No Yes Estimated Value: $

Address:

Description:

Is there a joint owner? No Yes

Explain any changes in the last 12 months:

(2) Other Real Estate. Estimated Value: $

Address:

Description:

Is there a joint owner? No Yes

Explain any changes in the last 12 months:

i. Vehicles.

Type of Vehicle Year, Make & Model Value Co-Owner

Explain any changes in the last 12 months:

j. Furniture, Appliances and Electronic Equipment exceeding $400 in value.

Description of Item Approximate Age Value

Explain any changes in the last 12 months:

k. Jewelry, Gems, Precious Metals, Coin or Stamp Collections, Other Collections, Artwork, Raw or Decorated Ivory.

Description of Item Location Value

Explain any changes in the last 12 months:

l. Other Personal Property.

Description of Item Location Value

Explain any changes in the last 12 months:

m. Commercial Fisheries Interests (IFQs or limited entry permits).

Value

Explain any changes in the last 12 months:

TOTAL ASSETS $

Total Assets at End of Previous Reporting Period: $

Change in Total Assets Since Previous Reporting Period: $

14. Ward’s Liabilities.

a. Real Estate Debts.

(1) Home described in #13(h)(1). Loan balance: $

(2) Property described in #13(h)(2). Description: Loan balance: $

Explain any changes in the last 12 months:

b. Other Loans.

Explain any changes in the last 12 months:

c. Credit Cards.

Explain any changes in the last 12 months:

d. Judgments/liens.

Explain any changes in the last 12 months:

e. Amounts Owed For Services.

Explain any changes in the last 12 months:

TOTAL LIABILITIES $

Total Liabilities at End of Previous Reporting Period: $

Change in Total Liabilities Since Previous Reporting Period: $

15. NET ASSETS

Total Assets from 13 a - m $

Total Liabilities from 14 a - e $

Net Estate Value $

Net Assets at End of Previous Reporting Period: $

Change in Net Assets Since Previous Reporting Period: $

16. Trusts.

Name of Trust:

Name and Address of Trustee:

If registered with the court, list trust registration no. State

Do you know what benefits the ward is supposed to receive from the trust? Yes No

Is the ward receiving the benefits from the trust that he/she is supposed to receive? Yes No I do not know.

Explain any changes in the last 12 months:

17. Did the ward help you prepare this report?

Yes No

Oath

I do solemnly swear (or affirm) that the information given in this report is true and correct to the best of my knowledge and belief.

Subscribed and sworn to or affirmed before me at , Alaska on , 20____.

I certify that on , I gave a copy of this report and its attachments to:

ward

ward’s attorney or guardian ad litem (if currently representing ward):

parent or guardian with whom ward resides (if any):

ward’s conservator (if a separate conservator has been appointed):

the following person(s) designated by court order: