Free Periodic Report of Guardian - West Virginia

IN THE CIRCUIT COURT OF _______________ COUNTY, WEST VIRGINIA
For Clerk's Use Only IN RE: ___________________________________________, DATE FILED: ____________________________________ A PROTECTED PERSON CASE NUMBER ___________ - G - __________

PERIODIC REPORT OF GUARDIAN
[West Virginia Code: §§ 44A-3-2 and 11]

INSTRUCTIONS FOR COMPLETION OF REPORT
A. This form is a required submission under West Virginia Code: § 44A-3-2. Pursuant to the provisions of West Virginia Code: § 44A-3-11, the first reports must be completed and filed with the Clerk of the Circuit Court on a semi-annual basis during the first twelve months, and then on February 1 of each year thereafter. You have the ooption and may elect to file this report on a calendar year basis and the due date for calendar year reports is April 15 of the succeeding year. Please note: If you elect to file on a calendar year basis, the report cannot cover a period of more than one (1) year. You are also required to file a report at least annually after the first report, unless the Court requires you to file additional reports, and you are also required to file a report if your appointment as guardian is terminated. This report, and any subsequent reports, must be filed with the Circuit Court Clerk on or before the due dates above. All information provided in this report must be printed or typed and be clearly readable. All information requested MUST be provided, if known. If unknown, you must state it is unknown. Please be sure you read and answer all questions carefully and in as much detail as possible. Answers to some questions may require more space than provided. If so, attach additional pages as needed and label each response on such page(s) with the number of the applicable question.

B. C. D. E.

PLEASE TURN TO THE NEXT PAGE TO BEGIN REPORT

SCA-CG 915G-1 / 6-00

Periodic Report of Guardian Page 1 of 4 Pages

Name of Protected Person: ___________________________________________

Court Case Number __________-G-___________

Name of Guardian: ___________________________________________ Date of Appointment: ______________________________ This report is your [check any applicable category]: __________ __________ first report final report __________ __________ periodic annual report other report ordered by Court

Date of this report: ________________________ covering a time period from ___________________ to _______________________ Date of your last report [if applicable]: ____________________ covering ___________________ to _________________________

1.

Describe the Protected Person's mental, physical and social condition during the time period covered by this report: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

2.

Describe the Protected Person's living arrangements during the time period covered by this report: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

3.

Describe the medical, educational, vocational and other professional services which were provided to the Protected Person during the time period covered by this report: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

SCA-CG 915G-2 / 6-00

Periodic Report of Guardian Page 2 of 4 Pages

4.

What is your opinion as to the adequacy of the Protected Person's care: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

5.

Do you agree with the current treatment and/or habilitation plan for the Protected Person? Explain your response. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

6.

What is your recommendation as to the need for continued guardianship? Explain your response. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

7.

Do you recommend any changes in the scope of the guardianship? If so, detail the changes recommended and explain the reasons for recommending such changes. ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

8.

Summarize your visits with, and activities on behalf of, the Protected Person: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

SCA-CG 915G-3 / 6-00

Periodic Report of Guardian Page 3 of 4 Pages

9.

In the space below, provide any information requested by the Court but not otherwise requested in this form: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

10.

In the space below, provide any further information which, in your opinion, the Court may find useful in reviewing the case of the Protected Person: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________ ____________________________________________________________________________________________________

11.

Are you requesting compensation for your services as guardian? If you responded with "YES," what is the amount of your request:

__________ YES

__________ NO

$ _____________________________ $ _____________________________

12.

What are the reasonable and necessary expenses you have incurred as guardian

[If you listed an amount in this question, attach an itemized listing of your reasonable and necessary expenses.]

STATE OF ___________________________________ COUNTY OF ________________________________, to-wit:

I, ________________________________________________, the guardian named in this report, do hereby certify that the information provided in this PERIODIC REPORT OF GUARDIAN is true, correct and complete to the best of my knowledge, information and belief. Given under my hand this _______ day of ____________________________, 20 _____________.

_________________________________________________________ GUARDIAN'S SIGNATURE

The foregoing was taken, subscribed and sworn to before me by the said _________________________________________, in my said county and state on this, the __________ day of __________________________________, 20_____________. Given under my hand and NOTARIAL SEAL. [AFFIX NOTARIAL SEAL] _________________________________________________________ NOTARY PUBLIC SCA-CG 915G-4 /6-00

Periodic Report of Guardian Page 4 of 4 Pages