Free pc663.pmd - Michigan

Approved, SCAO

JIS CODE: CDP

STATE OF MICHIGAN PROBATE COURT COUNTY
CIRCUIT COURT - FAMILY DIVISION

REPORT OF GUARDIAN ON CONDITION OF INDIVIDUAL WITH DEVELOPMENTAL DISABILITY

FILE NO.

This report should be completed annually by the guardian or more often if directed by the court. In the matter of 1. I,
Name (type or print)

, an individual with a developmental disability , am the guardian of the individual named above, and I report for to .
Date

the period
Date

2. Present age of the individual:

Individual's date of birth:

3. Current address and telephone number of the individual:

4. The individual's present living arrangement is: own home relative's home hospital or medical center guardian's home Relationship community placement home other: 5. The individual has been in the present residence since . Descriptions and addresses of every residence where the individual has lived during this reporting period and the length of stay at each residence are as follows:

6. I rate the individual's present living arrangements as
Explain if below average

excellent.

average.

below average.

7. I believe the individual is

content with the living situation.
Describe

unhappy with the living situation. I recommend a

more suitable residence as follows: 8. The individual's mental condition has
Describe the changes

remained about the same.

improved.

deteriorated.

9. The individual's physical health has
Describe the changes

remained about the same.

improved.

deteriorated.

10.The individual's social condition has
Describe the changes

remained about the same.

improved.

deteriorated.

(PLEASE SEE OTHER SIDE)
Do not write below this line - For court use only

Date Signature of reviewer Court action to be taken MCL 330.1631, MCR 5.409(A) PC 663 (12/08)

REPORT OF GUARDIAN ON CONDITION OF INDIVIDUAL WITH DEVELOPMENTAL DISABILITY

11. The individual has received the following services: medical. educational. vocational.
Describe

other professional services.

12. My visits with and activities on behalf of the individual were:

13. I believe the individual has the following needs:

14. I have the following questions concerning the individual or my responsibilities:

15. Other information requested by the court or necessary in the opinion of the guardian is as follows:

16. The guardianship

should

should not

be continued because:

17. As guardian, I have been ordered by the court to file an annual account which is attached. 18. Comments:

Date Signature of guardian

Address City, state, zip Telephone no.

STATEMENT BY STANDBY GUARDIAN I am the appointed standby guardian and am willing to continue to serve in the event the guardian dies, becomes unable to serve, or resigns from the guardianship.
Date Signature of standby guardian Name (type or print) Address City, state, zip Telephone no.