Annual Guardianship Plan

American LegalNet, Inc. www.FormsWorkFlow.com Facility Name, Address, and Phone Number Type of Facility Start Date of Residence Approximate Ending Date of Residence A B C D E F G H American LegalNet, Inc. www.FormsWorkFlow.com Note: American LegalNet, Inc. www.FormsWorkFlow.com Provider's Name Address, and Phone Number Type of Provider Number of Visits A B C D E F G American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com Right To: Answer American LegalNet, Inc. www.FormsWorkFlow.com Right To: Answer American LegalNet, Inc. www.FormsWorkFlow.com Description Rating American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com ANNUAL PHYSICIAN'S REPORT OF EXAMINATION 1. This report is based on an examination of the patient , which was made on: 2. DIAGNOSIS: 3.RECOMMENDED TREATMENT: 4. PROGNOSIS: 5. Current Level of Capacity: American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION AND SIGNATURE OF GUARDIAN(S) Co-Guardian American LegalNet, Inc. www.FormsWorkFlow.com CERTIFICATION AND SIGNATURE OF PREPARER CERTIFICATION AND SIGNATURE OF GUARDIAN'S ATTORNEY American LegalNet, Inc. www.FormsWorkFlow.com