Fill and Sign the Disability Benefits in the Estate Plan Passing the Means Test Form

GN -3485, 05/14 Annual Report on the Condition of the Minor W ard §54.25(1)(a), Wisconsin Statutes This form shall not be modified. It may be supplemented with additional mat erial. STATE OF WISCONSIN, CIRCUIT COURT, COUNTY IN THE MATTER OF Name of Minor Ward Date of Birth Amended Annual Report on the Condition of the Minor Ward Case No. 1. LOCATION AND ADDRESS OF THE MINOR WARD The minor ward lives at [Street, City, County, State, Zip] . 2. HEALTH AND LIVING CONDITIONS OF THE MINOR WARD A. The ward lives with me. The ward does not live with me . I personally observe the living conditions and care of the minor ward Daily Weekly Monthly Other: B. Has the minor ward’s health changed in the last year? No change Improved Worsened Please explain: 3. LEAST RESTRICTIVE ENVIRONMENT CONSISTENT WITH THE MINOR WARD’S NEEDS is an environment that provides the least possible restriction on the ward’s personal liberties and rights, and promotes the greatest possible integration of the ward into the community. A. Is the minor ward living in the least restrictive environment considering his /her needs? Yes No B Has your minor ward been transferred to a more or less restrictive environment during the past y ear? No change. To a less restrictive environment. To a more restrictive environment. Please explain change and d ate 4. RECOMMENDATIONS REGARDING THE MINOR WARD See attached File original with Court Official: Send copy to Board or Agency if listed here Guardian(s) Signature ► ► Date Signed Guardian’s Telephone Number Guardian’s Name and Address ( Check if address changed in last 12 months and indicate current address.)