Free GUARDIANSHIP ANNUAL REPORT - Alaska


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http://www.state.ak.us/courts/forms/pg-210f.pdf

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Preview GUARDIANSHIP ANNUAL REPORT
IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT____________________ In the Matter of the Protective Proceedings of: ) ) Name of Ward: ) ) Date of Birth: ) ) ) Residential location of ward: ) ) Ward's Telephone #: ) )

CASE NO. GUARDIANSHIP ANNUAL REPORT

Instructions
Please type or print clearly using black ink. In preparing the report, you must consult with the ward as much as possible. The court will treat the information in this report as confidential. If you are unable to complete this form without help, you may find assistance on the website of the Office of Public Advocacy (OPA): www.state.ak.us/guardianship. Your local library and court may also have a binder of helpful information entitled "Family Guardian Education Materials," prepared by the Alaska State Association for Guardianship and Advocacy. You may also call OPA at 269-3500 (in Anchorage), 451-5933 (in Fairbanks) or 1-877-957-3500. After completing this report, you must sign it under oath (or affirmation) in the presence of a notary public or court clerk. See last page. If you are a full guardian with the powers of a conservator, you must fill out the entire form. If you are a partial guardian and do not have the powers of a conservator (or if a separate conservator has been appointed), you do not need to fill out the financial information in paragraphs 10 through 16. The purpose of this report is to give the court as complete a picture as possible of the ward's current situation and what has happened in the last 12 months. Reporting Period This report covers the following period: From Information About Guardian Guardian's Name Mailing Address (box or street number) (city) (state) (ZIP) Check here if this mailing address is new. If you change your address, please notify the court. Residence Address (street address) Do you live with the ward? Relationship to ward:
Page 1 of 13 PG-210 (9/08)(cs) GUARDIANSHIP ANNUAL REPORT Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e) AS 13.26.118, .255, .380(b) & 13.06.100

To Daytime Phone

(city) No

(state)

Yes

In what areas do you have the authority to make decisions for the ward? housing medical care school & job training employment social & recreational activities financial management (you control ward's finances because you have conservator powers) Has a separate conservator been appointed for the ward? No Yes Name:

If you are a private guardian charging fees, is there a court order authorizing payment of fees and establishing an hourly rate and maximum monthly amount as required by Probate Rule 16 and AS 08.26.110? Yes No I do not charge fees. If you are a private professional guardian, do you have professional liability insurance? Yes. (Attach copy of current Declarations page showing liability limits.) No. Changes in Guardianship Needed

·

Is there a current need for change in the guardianship? If yes, explain:

No

Yes

If you want the court to change its order, please file form PG-190.

·

If this is a Public Guardian appointment, is a suitable private guardian available? No Yes

Information About Ward
1. Housing. a. Where does the ward live now? Name of facility or place: Address: (street address) Type of Residence: nursing home Has the ward moved in the past year?

(city) (state) assisted living home Yes No If yes, explain:

(ZIP)

b.

c.

If the ward lives in your home, do you charge the ward rent? If you live in the ward's home, are you paying rent? Yes

Yes No

No

d.

Have you discussed the ward's housing arrangement with the ward? Yes. Explain what the ward wants:

No, because:

Page 2 of 13 PG-210 (9/08)(cs) GUARDIANSHIP ANNUAL REPORT

Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e) AS 13.26.118, .255, .380(b) & 13.06.100

f.

If the ward lives in a nursing home, assisted living home, group home or other facility, (1) Is this the least restrictive setting in which services can be provided to the Yes No ward? (2) Have you participated in developing the facility's care plan for the ward? Yes No. (3) Do you believe the facility's care plan is a good one for the ward (in the Yes No Explain: ward's best interests)?

g.

Are there any problems with providing meals, clothing, house cleaning or transportation for the ward?

2.

Medical Care. a. Which of the following medical professionals has the ward seen in the past 12 months? Doctor's Name Phone No. Dates Seen Medical Doctor

Dentist Eye Doctor Ear Doctor Psychologist or Psychiatrist Other:

b.

Describe any medical problems (physical or mental) the ward has, and describe what is being done or will be done about them:

Page 3 of 13 PG-210 (9/08)(cs) GUARDIANSHIP ANNUAL REPORT

Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e) AS 13.26.118, .255, .380(b) & 13.06.100

c.

Describe any plans you have to change the care currently being provided for the ward's medical problems:

d.

Have you discussed these medical issues with the ward? Yes. Explain what the ward wants:

No. Explain why not:

e.

Are there any problems providing medical care or treatment for the ward?

f. g.

Is a no-code (Do Not Resuscitate) provision in place for the ward?

Yes

No

Did the ward, while the ward still had the capacity to do so, execute a durable power of attorney for health care or some other advance health care directive under AS 13.52.010 - .395 or another law? Yes No. If yes, who is the agent authorized to make health care decisions for the ward?

3.

School and Job Training. a. Does the ward attend school or any type of job training? Yes. Describe studies (include name and location of school): No, because: b. Is there any type of education or training that would benefit the ward?

c.

Have you discussed this with the ward? Yes. Explain what the ward wants:

No. Explain why not: 4. Work. a. Is the ward employed? No, because: Yes. Describe (include type of work, name of employer, address, phone, and how long employed):
Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e) AS 13.26.118, .255, .380(b) & 13.06.100

Page 4 of 13 PG-210 (9/08)(cs) GUARDIANSHIP ANNUAL REPORT

b.

If not employed, would it be in the ward's best interests to obtain employment?

c.

Have you discussed this with the ward? Yes. Explain what the ward wants:

No. Explain why not:

5.

Social and Recreational Activities. a. Describe activities the ward enjoys:

b.

Have you been able to help make these activities available to the ward?

c.

Do you have any plans concerning additional social and recreational activities for the ward?

6.

Contacts With Ward. a. If the ward does not live with you, how often have you visited the ward in the past 12 months?

b.

No Yes, as follows: Have there been any other contacts? Type of Contact Frequency of Contact by telephone by mail or e-mail through 3rd person: other:

7.

Decision Making. a. Have there been any changes in the ward's ability to make decisions about matters affecting the ward's health and safety?

Page 5 of 13 PG-210 (9/08)(cs) GUARDIANSHIP ANNUAL REPORT

Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e) AS 13.26.118, .255, .380(b) & 13.06.100

b.

When a decision has to be made about something for the ward (housing, medical care, education, employment, recreation, purchases, etc.), how are the decisions made? (1) Describe decisions made by ward alone:

(2)

Describe decisions made by guardian alone:

(3)

Describe decisions made by guardian and ward together:

8.

Community Resources (service providers, churches, government programs, charitable organizations, etc.). List the community organizations that are currently involved with the ward. Name of Organization Services Received Agency Phone

9.

Significant Actions. Describe any significant actions you have taken as guardian for the ward during the past 12 months:

You only have to fill out paragraphs 10 - 16 if you are a full guardian with authority to manage the ward's finances. If you do not have financial management authority, skip to paragraph 17.

Page 6 of 13 PG-210 (9/08)(cs) GUARDIANSHIP ANNUAL REPORT

Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e) AS 13.26.118, .255, .380(b) & 13.06.100

10.

Ward's Annual Income. (List only the income of the ward during the 12­month reporting period. Do not list your income.) Annual Amount Income Source Annual Amount Income Source Social Security Benefits: Wages: a. SSA: Dividends/Interest: b. SSI: Rental Income: Adult Public Assistance: Pension: Veterans Financial Benefits: Annuities: Other (describe): Alaska Longevity Bonus: Permanent Fund Dividend: Native Corporation Dividend: $0.00 Total Annual Income: Total Annual Income During Previous Reporting Period: $0.00 Change in Annual Income Since Previous Reporting Period Explain any difference more than $1000:

11.

Ward's Annual Expenses. (Money paid to anyone on behalf of ward or ward's legal dependents. Do not include your personal expenses. Attach extra pages if necessary.) Description Annual Amount Expense Nursing/ Assisted Living Home: Rent Payment: Mortgage Payment: Utilities: Transportation: Medical Treatment Costs Medications: Credit Card Payments: Food: Clothing: Recreation or Entertainment: Personal Expenses (include allowance): Income Tax & Property Tax: Home/Property Maintenance Costs: Insurance Home Insurance: Auto Insurance: Medical Insurance: Life Insurance: Gifts: Child/Spousal Support: Fees/Costs Paid to Guardian: Other (list all other payments made): Total Annual Expenses: Total Annual Expenses During Previous Reporting Period:
$0.00

Page 7 of 13 PG-210 (9/08)(cs) GUARDIANSHIP ANNUAL REPORT

Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e) AS 13.26.118, .255, .380(b) & 13.06.100

Change in Annual Expenses Since Previous Reporting Period Explain any difference more than $1000: 12. Money Controlled By Ward. Does the ward have sole control over any money? If yes, please explain:

$0.00

Yes

No

Is this money included in the income and expenses listed in #10 and #11? Explain: 13.

Yes

No

Ward's Assets at the end of this Reporting Period (Date: (List all assets the ward owns individually or jointly. Attach extra pages if necessary.) a. Cash on hand (not in an account) $ (amount) Explain any changes in the last 12 months: b. Burial Account Name of Bank or Institution Type of Account Account Number Balance (where located)

)

Explain any changes in the last 12 months: c. Alaska Native Corporation Dividend Account Name of Bank or Institution Type of Account Account Number Balance

Explain any changes in the last 12 months: d. List all other bank accounts, certificates of deposit, etc. Attach the most recent bank statement. Attach additional pages if necessary. Name of Bank or Institution Name(s) on Account Account Number Balance

Page 8 of 13 PG-210 (9/08)(cs) GUARDIANSHIP ANNUAL REPORT

Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e) AS 13.26.118, .255, .380(b) & 13.06.100

Explain any changes in the last 12 months: e. List all Brokerage Accounts, Stocks, Bonds, and Other Securities. Attach the most recent account statement. Attach additional pages if necessary. Name of Company Name(s) on Account Account Value on (date)

Explain any changes in the last 12 months: f. Retirement Accounts. Name of Company Beneficiary Current Value

Explain any changes in the last 12 months: g. Ward's Life Insurance Policies (policies the ward owns). Name of Company Beneficiary of Life Insurance Face Value of Life Insurance Cash Value of Life Ins.

Explain any changes in the last 12 months: h. Real Estate that Ward Owns (land and buildings). Attach tax assessment, if available. (1) Does ward own a home? Address: Description: Is there a joint owner? No Yes Explain any changes in the last 12 months:
Page 9 of 13 PG-210 (9/08)(cs) GUARDIANSHIP ANNUAL REPORT Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e) AS 13.26.118, .255, .380(b) & 13.06.100

No

Yes. Estimated Value: $

(2)

Other Real Estate. Address: Description: Is there a joint owner? No

Estimated Value: $

Yes

Explain any changes in the last 12 months:

i.

Vehicles. (List any cars, boats, snow machines, off-road vehicles, airplanes, etc.) Type of Vehicle Year, Make & Model Value Co-Owner

Explain any changes in the last 12 months:

j.

Furniture, Appliances and Electronic Equipment exceeding $400 in value. Attach additional pages if necessary. Description of Item Approximate Age Value

Explain any changes in the last 12 months:

k.

Jewelry, Gems, Precious Metals, Coin or Stamp Collections, Other Collections, Artwork, Raw or Decorated Ivory. Attach additional pages if necessary. Location Value Description of Item

Explain any changes in the last 12 months:

Page 10 of 13 PG-210 (9/08)(cs) GUARDIANSHIP ANNUAL REPORT

Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e) AS 13.26.118, .255, .380(b) & 13.06.100

l.

Other Personal Property. (List any item that has a value over $400. Please include any collectibles and any other items that are particularly susceptible to theft. Give details sufficient to allow a third party to identify the item. Attach extra pages, if necessary.) Location Value Description of Item

Explain any changes in the last 12 months: m. Commercial Fisheries Interests (IFQs or limited entry permits). Value

Explain any changes in the last 12 months: TOTAL ASSETS (Total value of all items in #13 a through m) Total Assets at End of Previous Reporting Period: Change in Total Assets Since Previous Reporting Period: 14.
0.00
0.00

$ $ $

Ward's Liabilities. (List all debts the ward owes, including mortgages, loans, credit card debt, etc. Attach extra pages if necessary.) a. Real Estate Debts. (1) Home described in #13(h)(1). Loan balance: $

(2) Property described in #13(h)(2). Description: Loan balance: $ Explain any changes in the last 12 months:

b.

Other Loans. Lender (Name & Address) Purpose (loan type) Loan Number Balance Due

Explain any changes in the last 12 months:

Page 11 of 13 PG-210 (9/08)(cs) GUARDIANSHIP ANNUAL REPORT

Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e) AS 13.26.118, .255, .380(b) & 13.06.100

c.

Credit Cards. Company (Name & Address) Card Card Number Balance Due

Explain any changes in the last 12 months:

d.

Judgments/liens. Description Balance Due

Explain any changes in the last 12 months:

e.

Amounts Owed For Services. Service Medical Services Attorney Services Guardian Services Other To Whom Owed Balance Due

(1) (2) (3) (4)

Explain any changes in the last 12 months:
0.00

TOTAL LIABILITIES (Total all items in #14 a through e): Total Liabilities at End of Previous Reporting Period: Change in Total Liabilities Since Previous Reporting Period: 15. NET ASSETS (Subtract Total Liabilities from Total Assets): Total Assets from 13 a - m Total Liabilities from 14 a - e Net Estate Value Net Assets at End of Previous Reporting Period: Change in Net Assets Since Previous Reporting Period:

$ $ $ $ $ $ $ $

0.00
0.00

0.00

0.00
0.00

Page 12 of 13 PG-210 (9/08)(cs) GUARDIANSHIP ANNUAL REPORT

Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e) AS 13.26.118, .255, .380(b) & 13.06.100

16.

Trusts. The ward is a beneficiary of the following trust(s) (meaning the ward has the right to receive benefits of some kind from the trust): Name of Trust: Name and Address of Trustee: If registered with the court, list trust registration no. State Do you know what benefits the ward is supposed to receive from the trust? Yes No Is the ward receiving the benefits from the trust that he/she is supposed to receive? Yes No I do not know. Explain any changes in the last 12 months:

17.

Did the ward help you prepare (provide information for) this report?

Yes

No

Oath I do solemnly swear (or affirm) that the information given in this report is true and correct to the best of my knowledge and belief.

Date Subscribed and sworn to or affirmed before me at on ______________________, 20____.

Guardian's Signature , Alaska

(SEAL)

Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires:

, I gave I certify that on a copy of this report and its attachments to: ward ward's attorney or guardian ad litem (if currently representing ward): parent or guardian with whom ward resides (if any): ward's conservator (if a separate conservator has been appointed): the following person(s) designated by court order:

Guardian's Signature

Page 13 of 13 PG-210 (9/08)(cs) GUARDIANSHIP ANNUAL REPORT

Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e) AS 13.26.118, .255, .380(b) & 13.06.100