Fill and Sign the Medical Statements Guardianship Form

IN THE COURT OF CHANCERY OF THE STATE OF DELAWARE       , C.M.#       Disabled Person ANNUAL UPDATE & MEDICAL STATEMENT (GUARDIAN must complete the section below.) I,       , was appointed Guardian of Guardian’s name       on       . Disabled person’s name Date of Final Order for Appointment of Guardianship 1. My current mailing address is the following:       2. My current telephone number is:       3. Name of Disabled Person:       Date of Birth: 4. Disabled Person’s Residence:       Type of facility: Disabled Person’s Home Guardian’s Home Group Home Foster Home Nursing Home State Facility Other (specify) Agency providing care (i.e. Easter Seals, Chimes, DDDS, etc):       Other agencies involved with the disabled person:       If there has been a change in residence since last review, give a reason for the change:       5. Describe the management of the disable person’s financial affairs:       If the guardian(s) do(es) not manage the disabled person’s financial affairs, who does?       Page 1 of 3 6. Have burial arrangements been established for the disabled person? Yes No If so, through what provisions:       7. Describe relationship with family (or interested parties):       8. Any additional information the Guardian desires to share with the Court:       9. Explain why this guardianship should be continued:             Date Guardian’s signature       Date Co-Guardian’s signature Page 2 of 3 (PHYSICIAN must complete the section below) The attending physician,       , last examined Physician’s name       on the following date       . Disabled person’s name Describe physical health of the disabled person/diagnosis:       Significant changes since last review:       Hospitalizations/Surgical procedures since last review:       Consequently, there is a continued need for guardianship of the disabled person. Yes No If No, why not?       __________________ ______________________________ Date Physician’s signature Page 3 of 3