Guardians Report {17.7}

PROBATE COURT OF STARK COUNTY, OHIO DIXIE PARK, JUDGE GUARDIANSHIP OF ______________________________________________________________________ CASE NO. ________________________ GUARDIAN'S REPORT [R.C. 2111.49 and SUP.R. 66.05(B)(2)] NOTE: If allotted space is inadequate to respond, write "See Exhibit" in the space and add appropriate exhibit letter sequence, then attach exhibit containing information requested for that space. 1. This is the (circle one): 1st 2nd 3rd 4th 5th 6th or ______________ Guardian's Report. 2. Ward's present address: __________________________________________________________________ City ___________________________________________ State ______________ Zip ______________ Telephone (_________) ____________________________ 3. Ward's living arrangements at the above address are best described as: a. His or her own apartment or home (includes assisted living facilities). b. Private home or apartment of: (1) the ward's guardian (2) a relative of the ward, whose name is ___________________________________________ and relationship is ______________________________________________________________ (3) a non relative whose name is __________________________________________________ c. A foster, group or boarding home. d. A nursing home e. A medical facility or state institution. f. Other (describe) __________________________________________________________________ __________________________________________________________________________ g. If c, d, e, or f is checked, complete the following: (1) The name of the home, facility or institution _______________________________________ _____________________________________________________________________________ (2) The name of an individual at the home, facility or institution who has knowledge and is authorized to give information to the Court about the ward. Name _______________________________________________________________________ Telephone Number (_____)______________________________________________________ 4. The Ward will be at the address given in Item 2. a. Indefinitely. b. Temporarily. The new address and telephone number is: (1) Unknown, I will provide this information when known. (2) _________________________________________________________________________ City ___________________________________________ State _____________________ Zip __________________________ Telephone (_____) ___________________________ FORM 17.7 - GUARDIAN'S REPORT Amended Date: March 1, 2017 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com CASE NO. _______________________ 5. Guardian's contact with the ward: a. Approximate number of times the guardian had contact with the ward during the period covered by this report: ___________ b. The nature of those contacts (phone, personal, or other) _______________________________________ ____________________________________________________________________________________ c. Date the ward was last seen by the guardian: ________________________________________________ 6. Have you observed any major change in the ward's physical or mental condition during the period covered by this report? Yes No If "Yes" is checked, briefly describe the changes ____________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 7. The care given to the ward is Adequate Not Adequate If "Not Adequate" is checked, explain. ___________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ 8. The guardianship should be Continued Not Continued If "Not Continued" is checked, explain. __________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 9. During the period covered by this report the ward has has not been seen by a physician. If the ward has been seen, the last date was ______________________________ _______________________________ and for the purpose of ____________________________________ 10. I currently serve as the guardian to ten or more wards and certify to the Court that I am unaware of any circumstances that may disqualify me from serving as guardian for this Ward. I have completed the continuing education requirement. (Attach Certificate of Completion if applicable) The continuing education requirement was waived. 11. Attached is a statement by a licensed physician, a licensed clinical psychologist, a licensed social worker, or a developmental disability team that has evaluated or examined the ward within three months prior to the date of this report regarding the need for continuing the guardianship. [R.C. 2111.49(A)(1)(I)] (Form 17.1) If an attorney has been consulted on this report: _________________________________________ Attorney for Guardian _________________________________________ Street _________________________________________ City, State, Zip Code _________________________________________ Phone Number ________________________________________ Attorney Registration No. Date: ___________________________________________ __________________________________________ Guardian's Printed Name __________________________________________ Guardian's Signature __________________________________________ Street __________________________________________ City, State, Zip Code __________________________________________ Phone Number Amended: March 1, 2017 (Knowingly giving false information on a Probate document is a criminal offense.) [R.C. 2921.13(A)(11)] FORM 17.7 ­ GUARDIAN'S REPORT PAGE 2 Discard all previous versions of this form American LegalNet, Inc. www.FormsWorkFlow.com