Guardians Report {17.7}

PROBATE COURT OF BUTLER COUNTY, OHIO IN THE MATTER OF 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) 2. Ward's present address: City Zip Telephone State 1st, 2nd, 3rd, 4th, 5th, 6th, or, Guardian's Report. 3. Ward's living arrangements at the above address are best described as: a. b. His or her own apartment or home (includes assisted living facilities). 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 A foster, group or boarding home. A nursing home. A medical facility or state institution. Other (describe) c. d. e. f. g. If c, d, e, or f is checked, complete the following: (1) The name of the home, facility or institution 4. (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 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: 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. 6. Date the ward was last seen by the guardian: 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 If "Not Adequate" is checked, explain: Adequate Not Adequate 8. The guardianship should be If "Not Continued" is checked, explain: Continued Not Continued has has not During the period covered by this report, the ward 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) 11. The continuing education requirement was waived. 9. 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 Date Guardian's Printed Name Street Guardian's Signature City, State, Zip Code Street Phone Number City, State, Zip Code Attorney Registration No. Phone Number (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 American LegalNet, Inc. www.FormsWorkFlow.com Amended: March 1, 2017 Discard all previous versions of this form