DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62546 (Rev. 07/08)
STATE OF WISCONSIN Chapter HFS 85, Wis. Admin. Code
CORPORATE GUARDIANSHIP ANNUAL REPORT
· Completion of this form is required by Chapter HFS 85.03(10), Wisconsin Administrative Code. Failure to complete and submit this form may result in the withdrawal of the Department of Health Services finding of suitability for your corporation (per Chapter HFS 85.04, Wis. Admin. Code). Direct questions about completion of this form to 608-266-6646. Return the completed form to: Corporate Guardianship Program Coordinator Division of Quality Assurance PO Box 2969 / 1 West Wilson Street, Room 950 Madison, WI 53701-2969
· ·
Name Organization
Address
City
State
Zip Code
Name Contact Person
Title Contact Person
Telephone Number
E-Mail Address
Number of Wards Approved to Serve
Actual Number of Wards Served This Year
Identify Disability Groups Served
Identify Geographic Areas Served
NUMBER AND TYPES OF PERSONS SERVED
Guardianships Temporary Guardian Standby Guardian Guardian of the Person Only Guardian of the Estate Only Guardian of Both the Person and Estate Personal / Financial Decision Making Conservatorships Spendthrifts SSA / SSI Representative Payee Child Guardian Other (Specify.)
STAFF MEMBERS (Employees and Volunteers)
Identify all staff members. For staff members added this year, attach a summary of qualifications and a job description. Attach additional pages as necessary Name Job Title Begin Date End Date
1. 2. 3. 4. 5. 6.
F-62546 (Rev. 07/08)
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BOARD MEMBERS
Identify board members. Attach additional pages if necessary. Name Office Title BegIn Date End Date
1. 2. 3. 4. 5. 6.
Are any staff or board members also members of any public human services agency? If "yes," list the name of staff or board member, the agency affiliation, and the county. Yes No
Summarize your fee and expenses policy. Describe how these amounts were determined. Identify court approved fees.
Briefly summarize your program activities over the past year.
Name Person Completing This Form
Title
Date Signed