Annual Report Of Guardian For Adult-Protected Person

FOR CLERK'S USE ONLY Name of Person Filing: _______________________________________ Mailing Address: _______________________________________ City, State, Zip Code: _______________________________________ Day/Evening Telephone: _______________________________________ Attorney Bar Number (if applicable) __________________________________ Self, Without a Lawyer, OR Representing: Attorney for _______________________________ SUPERIOR COURT OF ARIZONA MOHAVE COUNTY In the Matter of the Guardianship of Case No. _______________________________ ANNUAL REPORT OF GUARDIAN FOR ADULT / PROTECTED PERSON ____________________________________ An Incapacitated and/or Protected Person This annual report covers the period: FROM: _______________________(month/day/year) DUE: _______________________(month/day/year) TO: _______________________(month/day/year) Instructions to Guardian: Arizona law (A.R.S. §§14-5209(4) and 14-5315) requires every guardian of an adult to advise the court each year regarding their Ward. Please complete this report each year on the anniversary date of your appointment as guardian. When complete, mail the report to: Clerk of Superior Court, Mohave County Courthouse, PO Box 7000, Kingman, AZ 86402. You must also mail a copy of the report to anyone else who has appeared in the case. This includes the Ward's attorney, if the Ward is represented by an attorney. If the Ward is not represented by an attorney, you must mail a copy to the Ward, if he or she is at least 14 years old. You must also fill out the Affidavit 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 on which you mailed it. (If necessary, additional pages may be attached.) I am the guardian and make these statements: 1. Information about the Ward. Ward's Name: _________________________________________________________________________ Ward's Date of Birth: ____________________________________________________________________ Ward's Address:________________________________________________________________________ Ward's Telephone:______________________________________________________________________ Residential situation (private home, boarding home, nursing home, etc.) _____________________________________________________________________________________ 2. Information about person in charge of home or facility. Name:________________________________________________________________________________ Facility:_______________________________________________________________________________ Address:______________________________________________________________________________ Telephone:____________________________________________________________________________ Revised: 10/27/2011 Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Case No.________________________________ 3. Information about the Ward's Doctor. Ward's Current Doctor: __________________________________________________________________ Doctor's Address:_______________________________________________________________________ Doctor's Telephone Number:______________________________________________________________ 4. Information about the Ward's physical and mental health. A. B. Date the Ward was last seen by a doctor:_____________________________________________ Major changes in the Ward's physical and/or mental condition in the last year as observed by the guardian: ______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ C. Physician's report is attached as Exhibit "A". 5. Information about the Ward's Guardian. Guardian's Name: ______________________________________________________________________ Guardian's Address: ____________________________________________________________________ Guardian's Telephone: __________________________________________________________________ 6. Information about the Guardianship. Number of times the Guardian has seen the Ward in the last 12 months:____________ Date of last visit: ________________. The Guardian's opinion about whether the guardianship should continue: (Explain.) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 7. Information about the person responsible for managing the Ward's assets: Person responsible for managing Ward's assets: Name: _______________________________________________________________________________ Address: _____________________________________________________________________________ Telephone Number: ____________________________________________________________________ 8. Summary of governmental services provided to the ward and individual responsible for Ward's affairs with that agency: ______________________________________________ Services provided ______________________________________________ Services provided ______________________________________________ Services provided _________________________________ Agency/Individual _________________________________ Agency/Individual _________________________________ Agency/Individual Revised: 10/27/2011 Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com Case No.________________________________ Respectfully submitted this ___________ day of _______________, 20_____. ________________________________________ Print Guardian's Name 9. ________________________________________ Signature of Guardian AFFIDAVIT OF MAILING: Under penalty of perjury, I state to the Court that I have mailed or will mail a copy of this Annual Report of Guardian to the following people at the following address(es) on this date: ________________ (Month / Day / Year) Name: Address: ________________________________________________________________________ ________________________________________________________________________ City, State, Zip Code________________________________________________________________ Name: Address: ________________________________________________________________________ ________________________________________________________________________ City, State, Zip Code________________________________________________________________ Name: Address: ______________________________________________________