Initial Report (Guardianship)

SUPREME COURT OF THE STATE OF NEW YORK ____________________________COUNTY County INITIAL REPORT INDEX NO. _______________ Number/Year --------------------------------------------------------------------X In the Matter of ____________________________. Name of Incapacitated Person Please mark appropriate boxes with [ X ], and type or print all requested information. For more space, please use reverse side of page of question being answered.. ("IP" designates Incapacitated Person in this report) --------------------------------------------------------------------X DATE OF ORDER APPOINTING GUARDIAN: __________________________ APPOINTING JUDGE: ____________________________________________ PERSONS FILING THIS REPORT What is the status of your educational requirements under MHL § 81.30? Waived Completed _____________________________________________________________________________ Name Address _____________________________________________________________________________ Phone Relationship* _____________________________________________________________________________ Name Address _____________________________________________________________________________ Phone Relationship _____________________________________________________________________________ Name Address _____________________________________________________________________________ Phone Relationship _____________________________________________________________________________ Name Address _____________________________________________________________________________ Phone Relationship G G G G G G G G *Part 36 appointees from OCA Fiduciary List: enter Fiduciary Identification Number. All others: enter a relationship, such as, parent, spouse, child, friend. FILING STATUS A. B. C. G Sole Guardian of Person G Sole Guardian of Property G Sole Guardian of Person and Property D. E. F. G Co-Guardians of Person G Co-Guardians of Property G Co-Guardians of Person and Property 1 American LegalNet, Inc. www.FormsWorkflow.com IP's PERSONAL DATA 1. IP's AGE: 2. IP resides in: a. G Community at: Address Phone Years in residence G This address is the IP's own home, which is G rented G The IP lives here alone. G The IP lives here with others: Name Name G owned. Relationship Relationship G This address is the home of another. Name Relationship b. G Facility: Facility Name Address Phone ______________________________________________________________________________________ FAX Date Admitted Name of Social Worker 3. Language of IP: 4. Citizenship: G English G Spanish G US G Other G Other PERSONAL NEEDS (Complete if your filing status is A, C, D or F) 5. Primary Care Physician: Name Address Phone Frequency of examinations Date of last examination Primary Diagnosis 6. Psychiatrist/Psychologist or Other Mental Health Provider: Name Address Phone Frequency of examinations Date of last examination Primary Diagnosis 7. Dentist: Name Address Phone Frequency of examinations Date of last examination 2 American LegalNet, Inc. www.FormsWorkflow.com Complete the following ONLY if the IP resides IN THE COMMUNITY. 8. Pharmacy: Name Address Phone 9. List professionals and service agencies (e.g., geriatric care managers, social workers, home healthcare agencies, social service agencies, "meals on wheels") assisting IP. Name Address Phone Profession/Service Name Address Phone Profession/Service Name Address Phone Profession/Service Name Address Phone Profession/Service 10. List Day Care Programs or other regularly attended programs for nutrition, rehabilitation, socialization, etc.. Name Address Phone Frequency of Attendance Name Address Phone Frequency of Attendance Name Address Phone Frequency of Attendance Name Address Phone Frequency of Attendance PROPERTY/FINANCIAL MANAGEMENT (Complete if your filing status is B, C, E or F and report all liquid assets, personal property, real property and income you are AUTHORIZED to take into your possession, management and control, AS GUARDIAN) 11. Liquid Assets: a. [ ] Cash Accounts: Have you changed the title of accounts to your name, as guardian? [ Institution Acct. Type/Acct. No. Amount ] Yes ] Yes ] Yes ] Yes [ [ [ [ ] No ] No ] No ] No [ Institution Acct. Type/Acct. No. Amount [ Institution Acct. Type/Acct. No. Amount [ Institution Acct. Type/Acct. No. Amount TOTAL (Accounts in any one institution should not exceed $100,000 in order to avoid the loss of FDIC coverage.) b. [ ] Mutual Funds, Securities and Brokerage Accounts: Have you changed the title of accounts 3 American LegalNet, Inc. www.FormsWorkflow.com to your name, as guardian? [ Institution Acct. Type/Acct. No. Amount ] Yes ] Yes ] Yes ] Yes [ [ [ [ ] No ] No ] No ] No [ Institution Acct. Type/Acct. No. Amount [ Institution Acct. Type/Acct. No. Amount [ Institution Acct. Type/Acct. No. Amount TOTAL c. [ ] Stocks: Have you changed the title on certificates to your name, as guardian? [ Corporation No. of shares Value ] Yes ] Yes ] Yes ] Yes [ [ [ [ ] No ] No ] No ] No [ Corporation No. of shares Value [ Corporation No. of shares Value [ Corporation No. of shares Value TOTAL d. [ ] Bonds: Have you changed the title on bonds to your name, as guardian? [ Issuing govt./agcy./corp. Value ] Yes ] Yes ] Yes ] Yes [ [ [ [ ] No ] No ] No ] No [ Issuing govt./agcy./corp. Value [ Issuing govt./agcy./corp. Value [ Issuing govt./agcy./corp. Value TOTAL e. Other: list any other liquid asset, giving type, location and value. : Have you changed title to these assets to your name, as guardian, or 4 American LegalNet, Inc. www.FormsWorkflow.com is a change not applicable (N/A)? [ Type Location Value ] Yes ] Yes ] Yes ] Yes [ [ [ [ ] No ] No ] No ] No [ [ [ [ ] N/A ] N/A ] N/A ] N/A [ Type Location Value [ Type Location Value [ Type Location Value TOTAL f. TOTAL VALUE OF LIQUID ASSETS: BOX A 12. Personal Property (e.g., cars, boats, furniture, jewelry, artwork) : Description Location Value Description Location Value Description Location Value Description Location Value Description Location Value Description Location Value Description Location Value Description Location Value TOTAL VALUE OF PERSONAL PROPERTY: BOX B 13. Real Property (e.g., vacant land, residential [including cooperative apartments and condominiums] commercial or income producing property): 5 American LegalNet, Inc. www.FormsWorkflow.com In the letter you received at your appointment, you were instructed about filing the "Statement Identifying Real Property" (Form #3 attached to letter). Attach a copy of form(s