Annual Report Of Guardian {PBGCG92f}

Person Filing: Address (if not protected): City, State, Zip Code: Telephone: Email Address: Lawyer's Bar Number: Licensed Fiduciary Number: _____________________________________ Representing Self, without a Lawyer or Attorney for Petitioner OR FOR CLERK'S USE ONLY Respondent SUPERIOR COURT OF ARIZONA IN MARICOPA COUNTY In the Matter of Guardianship for: Case Number PB: ANNUAL REPORT OF GUARDIAN DUE: Name of the Protected Person, the WARD Month Date Year Instructions to Guardian: Arizona law (A.R.S.§14-5209(B)(5) and §14-5315), and Arizona Rules of Probate Court Procedure Rule 30(c) requires every guardian of a protected or incapacitated adult or minor to advise the court each year regarding their Ward. Complete this report each year and file it on or before the date listed in the Order or if no date is specified, on or before the anniversary date of the "Letters of Appointment". When complete, mail to: Probate Court Administration: 125 West Washington, Phoenix, Arizona 85003 You must also mail a copy of the report to anyone else who has "appeared" in the case and fill out the Declaration of Mailing at the end of the report to show the names and addresses of all the people to whom you mailed the report and the date of mailing. Refer to the document "Instructions: How to Fill out the Probate Court Annual Report of Guardian" to make sure you have completed this report correctly and completely and that you have provided copies to all persons required by law. I am the Guardian and make these statements: 1. REPORTING PERIOD: This annual report covers the period FROM: Month Date Year TO: Month Date Year American LegalNet, Inc. www.FormsWorkFlow.com ©Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Page 1 of 4 PBGCG92f-050113 Case No. 2. Information about the Ward, the protected or incapacitated person: Ward's Name: Ward's Date of Birth: Ward's Address: Ward's email: Telephone: 3. Living Situation: A. Describe the residential situation where the Ward lives (private home, boarding home, nursing home, etc.) B. Give the name of the facility, address, name and telephone number of the person in charge of the home or facility. Name of Person in Charge: Name of Facility: Address: Telephone Number: Email Address: C. PRIMARY WEEKDAY LOCATION: Monday-Friday, 8:00 A.M. TO 5:00 P.M., that the Ward can usually be found at: (List full address below) 4. PHYSICIANS: Please list the name of the ward's primary physician, and any other medical specialists the ward has seen during the past year. Doctor's Name: Doctor's Address: Doctor's Telephone Number: Doctor's Email Address: Doctor's Name: Doctor's Address: Doctor's Telephone Number: Doctor's Email Address: Specialist's Name: Specialist's Address: Specialist's Telephone: Specialist's Email Address: American LegalNet, Inc. www.FormsWorkFlow.com ©Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Page 2 of 4 PBGCG92f-050113 Case No. 5. Ward's PHYSICAL and MENTAL HEALTH. A. Date the Ward was last seen by a doctor: B. Changes in Ward's health. Have there been any major changes in the Ward's physical and/or mental condition in the last year? If so, please describe the change. C. Attach a copy of the doctor's report about the Ward's current physical and mental condition. 6. ABOUT the Ward's GUARDIAN. Guardian's Name: Guardian's Address: Telephone Number: Email Address: 7. GUARDIANSHIP STATUS. A. Number of visits the Guardian has seen the Ward in the last 12 months: B. Date of the last visit: _____________ C. The Guardian's opinion about whether the guardianship should continue: (Explain.) 8. ASSET MANAGEMENT: Who is the person responsible for managing the Ward's assets? Name: Address: Telephone Number: Email Address: 9. BENEFITS RECEIVED: Does the ward receive any local, county, state, or federal agency benefits? (SSI, AHCCS, Medicaid, Food stamps) Please describe below: AGENCY CASEWORKER/CONTACT TYPE OF BENEFIT ©Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Page 3 of 4 PBGCG92f-050113 American LegalNet, Inc. www.FormsWorkFlow.com Case No. 10. SERVICES RECEIVED: Does the ward receive any local, county, state, or federal agency services? If so, write in the name(s) of the agency, the contact name, and describe the services received by the ward. AGENCY CASEWORKER/CONTACT TYPE OF SERVICE 11. DECLARATION OF MAILING: I state to the Court under penalty of perjury that I mailed this Annual Report of Guardian to the following people at the following address(es) on this Month/Day/Year:____________________________. UNDER PENALTY OF PERJURY: By signing below, I state to the Court that the contents of this Annual Report of Guardian are true and correct to the best of my knowledge and belief. DATED: Signature of Guardian PRINTED Name American LegalNet, Inc. www.FormsWorkFlow.com ©Superior Court of Arizona in Maricopa County ALL RIGHTS RESERVED Page 4 of 4 PBGCG92f-050113