Fill and Sign the Guardian S Report Adult Colorado Form

 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): 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. 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 (REQUIRED): ____________________________________ Date of Birth (REQUIRED): _____________ Sex (REQUIRED): ________________ Address: (Include Name of Living Center or Nursing Home) City: State: Zip Code: Telephone Number: Last 4 digits of Social Security # __________________ Guardian’s Information:  Check if Updated Information from last report Name: ____________________________________________________Date of Birth: ___________________ Last 4 digits of Social Security #: _____________________________ NOTE: Agency designees and professional fiduciaries need not provide their DOB or last 4 digits of their SSN. Occupation: _____________________ Your Relationship to Ward: __________________________ Address: __________________________________________________________________ Apt. #: __________ City: ___________________ State: ______ Zip Code: _________ E-Mail Address: _______________________ JDF 850 R8/17 GUARDIAN’S REPORT - ADULT Page 1 of 7 ©2017 Colorado Judicial Department for use in the Courts of Colorado Telephone Numbers: Home ___________________ Work ____________________ Cell ___________________ 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: ____________________________________________________Date of Birth: ____________________ Last 4 digits of Social Security #_____________________________ NOTE: Agency designees and professional fiduciaries need not provide their DOB or last 4 digits of their SSN. Occupation: _____________________ Your Relationship to Ward: _________________________ Address: __________________________________________________________________ Apt. #: __________ City: ______________________ State: ____ Zip Code: ________ E-Mail Address: _______________________ Telephone Numbers: Home ___________________ Work ____________________ Cell ___________________ 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: ___________________________________ Telephone Number: __________________________ 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. Date of Move Name of Facility and Address Type of Residence Reason for Change II. STATUS INFORMATION Y es N o A. Do you recommend that the guardianship continue?   If No , explain: ______________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ B. Do you recommend any changes to the guardianship?   If Yes , explain: _____________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ C. Do you wish to remain guardian?   If No , explain: ______________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ JDF 850 R8/17 GUARDIAN’S REPORT - ADULT Page 2 of 7 ©2017 Colorado Judicial Department for use in the Courts of Colorado 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 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. Have 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. Please describe in detail any medical services provided to the Ward: Please list any medications provided to the Ward: JDF 850 R8/17 GUARDIAN’S REPORT - ADULT Page 3 of 7 ©2017 Colorado Judicial Department for use in the Courts of Colorado 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? (date) D. Indicate how long your visits are and summarize your activities with and on behalf of the Ward. JDF 850 R8/17 GUARDIAN’S REPORT - ADULT Page 4 of 7 ©2017 Colorado Judicial Department for use in the Courts of Colorado 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: 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: JDF 850 R8/17 GUARDIAN’S REPORT - ADULT Page 5 of 7 ©2017 Colorado Judicial Department for use in the Courts of Colorado Complete this section only if there is no conservatorship and the guardian has custody of funds. 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 Beginning balance of bank accounts (savings, checking, etc.) $ Plus money received (Social Security, SSI, pension, disability, interest, etc.) from any source on behalf of the Ward +$ Less total fees to care providers -$ Less total monies paid to the Ward, 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 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. (Checking this box requires you to remove JDF number and copyright at the bottom of the form.) V ERIFICATION I swear/affirm under penalty of perjury, that I have read the foregoing GUARDIAN’S REPORT - ADULT and that the statements set forth therein are true and correct to the best of my knowledge. §15-10-310, C.R.S. _______________________________________ ______________________________________ Guardian’s Signature Date Co-Guardian’s Signature Date 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. JDF 850 R8/17 GUARDIAN’S REPORT - ADULT Page 6 of 7 ©2017 Colorado Judicial Department for use in the Courts of Colorado Certificate of Service I certify that on _______________________ (date) the original was e-filed/filed with the Court and a copy of this Guardian’s Report was served on each of the following: Name of person receiving this document (Interested Persons) Relationship to Ward Address Manner of Service** Ward ** Insert hand delivery, first class U.S. Mail, certified U.S. Mail, E-filed, Fax or other method allowed under Colorado law. X _________________________________________________ Signature JDF 850 R8/17 GUARDIAN’S REPORT - ADULT Page 7 of 7 ©2017 Colorado Judicial Department for use in the Courts of Colorado 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.