Fill and Sign the Residential Location of Ward Form

Probate Rules 16(e)(1)(C), 16(e)(3) & 17(f) AS 13.26.276 - .286, .510, .570 & 13.06.100 Page 1 of 12 PG-215 (4/17)(cs) FINAL GUARDIANSHIP REPORT IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT____________________ In the Matter of the Pr otective Proceedings of: ) ) Name of Ward: ) ) Date of Birth: ) ) Residential location of ward: ) ) ) CASE NO. Ward’s Telephone #: ) ) FINAL GUARDIANSHIP REPORT Instructions To Guardian Please type or print clearly using black ink. In preparing the report, you must consult with the ward as much as possible (if the ward is still li ving). The court will treat the information in this report as confidential. I f 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 unde r oath (or affirmation) in the presence of a notary public or court clerk. See last page. If you were a full guardian with the powers of a conservator, you must fill out the entire form. If you were a partial guardian and did not have the powers of a conservator (or if a separate conservator was appointed), you do not need to fill out the financial information in paragraphs 10 through 17. The purpose of this report is to tell the court why your service as guardian is ending and what has happened to the ward and the ward’s assets since you filed your last annual report. Reporting Period This report covers the period: From the end of the last reporting period: To the date my services as guardian ended: Information About Guardian Guardian’s Name Daytime Phone Mailing Address (box or street number) (city) (state) (ZIP) Check here if this mailing address is new. Relationship to ward: Probate Rules 16(e)(1)(C), 16(e)(3) & 17(f) AS 13.26.276 - .286, .510, .570 & 13.06.100 Page 2 of 12 PG-215 (4/17)(cs) FINAL GUARDIANSHIP REPORT In what areas did you have the authority to make decisions for the ward? housing medical care school & job training employment social & recreational activities financial management (you controlled ward’s finances because you had conservator powers) Was a separate conservator appointed for the ward? No Yes Name: Reason For Ending Guardianship My guardianship of the ward has ended because: The ward died on at (date) (location) A copy of the death certificate is attached. I did did not have possession of the ward’s will. On , 20 , I delivered the ward’s will to the court for safekeeping, as required by AS 13.26.545(e), and informed the executor or a b eneficiary named in the will that the will h ad been so delivered. Name of person n otified: I resigned as guardian. A new guardian, , has been appointed. (name) I was removed by the court. The court has terminated the guardianship because Other (Explain): If the ward is deceased or if the guardianship has been terminated because the ward regained capacity, you n eed not fill out paragraphs 1-9. Skip to paragraphs 10-17. You must fill out paragraphs 10 - 17 if you were a full guardian with authority to manage the ward’s finances. If you did not have financial management authority, skip to the signature section on the last page. Information About Ward 1.Housing . a. Where does the ward live now (name of facility or place)? Who takes care of the ward? Type of Residence: nursing home assisted living home Probate Rules 16(e)(1)(C), 16(e)(3) & 17(f) AS 13.26.276 - .286, .510, .570 & 13.06.100 Page 3 of 12 PG-215 (4/17)(cs) FINAL GUARDIANSHIP REPORT b. What is the ward’s opinion of the ward’s current living arrangements? 2.Medical Care . a. Which of the following medical professionals has the ward s een since the last report to the court? Doctor’s Name Phone No . Dates Seen Medical Doctor Dentist Eye Doctor Ear Doctor Psychologist or Psychiatrist Other: b. Describe any medical services and ment al health treatment provided to the ward since the last report to the court: c. Are there any problems providing medical care or treatment for the ward? d. Is a no-code (Do Not Resuscitate ) provision in place for the ward? Yes No e. Did the ward, while the ward still ha d the capacity to do so, execute a durable power of attorney for health care or some other advance health care directive Probate Rules 16(e)(1)(C), 16(e)(3) & 17(f) AS 13.26.276 - .286, .510, .570 & 13.06.100 Page 4 of 12 PG-215 (4/17)(cs) FINAL GUARDIANSHIP REPORT under AS 13.52.010 - .395 or another law? Yes No. If yes, who is the agent authorized to make health care decisions for the ward? 3.School and Job Training . Since the last report to the court, did the wa rd attend school or receive any type of job training? No Yes. Describe studies (include name and location of school): 4.Work. Was the ward employed at any time during the period since the last report to the court? No Yes. Describe (include type of work, name of employer, address, phone, and how long employed): 5. Contacts With Ward . a. If the ward did not live with you, how often did you visit the ward in the period since the last report to the court? b. Were there any other contacts? No Yes, as follows: Type of Contact How Often by telephone by mail or e-mail through 3rd person: other: 6. Decision Making . Have there been any changes in the ward’s ability to make decisions about matters affecting the ward’s health and safety? 7. Community Resources (service providers, churches, government programs, charitable organizations, etc.). List the community or ganizations that are currently involved with the ward. Name of Organization Services Received Agency Phone Probate Rules 16(e)(1)(C), 16(e)(3) & 17(f) AS 13.26.276 - .286, .510, .570 & 13.06.100 Page 5 of 12 PG-215 (4/17)(cs) FINAL GUARDIANSHIP REPORT 8. Significant Actions. Describe any significant acti ons you took as guardian for the ward during the period since your last report was filed with the court: 9. Additional Information . List any additional information about the wa rd that you wish to report to the court: You only have to fill out paragraphs 10 – 17 if you were a full guardian with authority to manage the ward’s finances. If you did not have financial management authority, skip to the signature section on the last page. 10.Ward’s Income Since Last Annual Report. (List only the income of the ward. Do not list your income.) Amount Received Amt. Received Since Last Since Last Income Source Annual Report Income Source Annual Report Social Security Benefits: Wages: a. SSA: Dividends/Interest: b. SSI: Rental Income: Adult Public Assistance: Pension: Veterans Financial Benefits: Annuities: Alaska Longevity Bonus: Other (describe): Permanent Fund Dividend: Native Corporation Dividend: Total Income Received Since Last Annual Report: Probate Rules 16(e)(1)(C), 16(e)(3) & 17(f) AS 13.26.276 - .286, .510, .570 & 13.06.100 Page 6 of 12 PG-215 (4/17)(cs) FINAL GUARDIANSHIP REPORT 11. Ward’s Expenses Since La st Annual Report. (Money paid to anyone on behalf of ward or ward’s legal dependents. Do not include your personal expenses. Attach extra pages if necessary.) Amount SpentSince Last Expense Description Annual Report 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: Insurance Home Insurance: Auto Insurance: Medical Insurance: Life Insurance: Gifts: Child/Spousal Support: Fees/Costs Paid to Guardian: Burial Expenses: Other (list all othe r payments made): Total Expenses Since the Last Annual Report: 12.Money Controlled by Ward. Since the last annual report was filed, did 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: Probate Rules 16(e)(1)(C), 16(e)(3) & 17(f) AS 13.26.276 - .286, .510, .570 & 13.06.100 Page 7 of 12 PG-215 (4/17)(cs) FINAL GUARDIANSHIP REPORT 13. Ward’s Assets as of . (List all assets the ward owned individually (date) or jointly. Attach extr a pages if necessary.) a. Cash on hand (not in an account) $ (amount) (where located) Explain any changes since last report: b. Burial Account Name of Bank or Institution Type of Account Account Number Balance Explain any changes since last report: c. Alaska Native Corporation Dividend Account Name of Bank or Institution Type of Account Account Number Balance Explain any changes since last report: d. List all other bank accounts, certificates of deposit, etc. Attach the most recent bank statement. Attach additional pages if necessary. Name of Bank or Institution Name(s) on Account Account Number Balance Explain any changes since last report: e. List all Brokerage Accounts, Stoc ks, Bonds, and Other Securities. Attach the most recent account statement. Attach additional pages if necessary. Name of Company Name(s) on Account Account Value on (date) Explain any changes since last report: Probate Rules 16(e)(1)(C), 16(e)(3) & 17(f) AS 13.26.276 - .286, .510, .570 & 13.06.100 Page 8 of 12 PG-215 (4/17)(cs) FINAL GUARDIANSHIP REPORT f. Retirement Accounts. Name of Company Beneficiary Current Value Explain any changes since last report: g.Life Insurance Policies (policies the ward owns). Name of Company Beneficiary of Life Insurance Face Value of Life Insurance Cash Value of Life Ins. Explain any changes since last report: h. Real Estate that Ward Owns (land and buildings). Attach tax assessment, if available. (1) Does ward own a home? No Yes. Estimated Value:$ Address: Description: Is there a joint owner? No Yes Explain any changes since last report: (2) Other Real Estate. Estimated Value: $ Address: Description: Is there a joint owner? No Yes Explain any changes since last report: Probate Rules 16(e)(1)(C), 16(e)(3) & 17(f) AS 13.26.276 - .286, .510, .570 & 13.06.100 Page 9 of 12 PG-215 (4/17)(cs) FINAL GUARDIANSHIP REPORT i. Vehicles. (List any cars, boats, snow machines, off-road vehicles, airplanes, etc.) Type of Vehicle Year, Make & Model Value Co-Owner Explain any changes since last report: j. Furniture, Appliances and Electroni c Equipment exceeding $400 in Value. Attach additional pages if necessary. Description of Item Approximate Age Value Explain any changes since last report: k.Jewelry, Gems, Precious Metals, Co in or Stamp Collections, Other Collections, Artwork, Raw or Decorated Ivory. Attach additional pages if necessary. Description of Item Location Value Explain any changes since last report: l. Other Personal Property. (List any item that has a value over $400. Please include any collectibles and any other items that are particularly susceptible to theft. Give details sufficient to allow a third party to identify the item. Attach extra pages, if necessary.) Description of Item Location Value Explain any changes since last report: Probate Rules 16(e)(1)(C), 16(e)(3) & 17(f) AS 13.26.276 - .286, .510, .570 & 13.06.100 Page 10 of 12 PG-215 (4/17)(cs) FINAL GUARDIANSHIP REPORT m. Commercial Fisheries Interests (IFQs or limited entry permits). Value Explain any changes since last report: TOTAL ASSETS (Total value of all items in #13 a through m) $ Total Assets at End of Previous Reporting Period: $ Change in Total Assets Since Previous Reporting Period: $ 14.Ward’s Liabilities as of . (date) (List all debts the ward owes. Attach extra pages if necessary.) a. Real Estate Debts. (1) Home described in #13(h)(1). Loan balance: $ Explain any changes since last report: (2) Property described in #13(h)(2). Description: Loan balance: $ Explain any changes since last report: b. Other Loans. Lender (Name & Address) Purpose (loan type) Loan Number Balance Due Explain any changes since last report: c. Credit Cards. Company (Name & Address) Card Card Number Balance Due Explain any changes since last report: Probate Rules 16(e)(1)(C), 16(e)(3) & 17(f) AS 13.26.276 - .286, .510, .570 & 13.06.100 Page 11 of 12 PG-215 (4/17)(cs) FINAL GUARDIANSHIP REPORT d. Judgments/liens. Description Balance Due Explain any changes since last report: e.Amounts Owed For Services. Service To Whom Owed Balance Due (1) Medical Services (2) Attorney Services (3) Guardian Services (4) Other Explain any changes since last report: TOTAL LIABILITIES (Total all items in #14 a through e): $ Total Liabilities at End of Previous Reporting Period: $ Change in Total Liabilities Since Previous Reporting Period: $ 15.NET ASSETS (Subtract Total Liabilities from Total 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. The ward is a beneficiary of the followi ng trusts(s) (meaning the ward has the right to receive benefits of some kind from the trust): 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 since last report: Probate Rules 16(e)(1)(C), 16(e)(3) & 17(f) AS 13.26.276 - .286, .510, .570 & 13.06.100 Page 12 of 12 PG-215 (4/17)(cs) FINAL GUARDIANSHIP REPORT 17. Assets Released. The ward’s assets were released as follows: To Whom Released Authority of Person To Asset Released Date (Name and Address) Receive This Property * * For authority, list recipient’ s role, such as former ward, new guardian, personal representative of deceased ward’s estate, special administrator, temporary property custodian or heir. 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. Date Guardian’s Signature Subscribed and sworn to or affirmed before me at , Alaska on ______________________, 20____. (SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: I certify that on , I gave a copy of this report and its attachments to: ward ward’s attorney or guardian ad lite m (if currently representing ward): parent or guardian with whom ward resides (if any): ward’s conservator (if a separa te conservator was appointed): the following person(s) designated by court order: Guardian’s Signature