Free GUARDIANSHIP ANNUAL REPORT - Alaska

IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT____________________ In the Matter of the Protective Proceedings of: ) ) ) Name of Minor: ) ) Date of Birth: ) )

CASE NO. ANNUAL REPORT ON GUARDIANSHIP OF A MINOR

Instructions
Please type or print clearly using black ink. The court will treat the information in this report as confidential. 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. The purpose of this report is to give the court as complete a picture as possible of the minor's current situation and what has happened in the last 12 months. You must file a report every year until the guardianship ends. Your final report will be for the year during which the minor reaches age 18 (or the guardianship otherwise ends). File the final report as soon as possible after the minor turns 18. 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 minor? Relationship to minor: Yes No (city) (state) Daytime Phone To

Changes in Guardianship Needed
Should any changes be made in the guardianship? If yes, explain: No Yes

If you want the court to change its order, please file form PG-190.
Page 1 of 5 PG-640 (10/06)(cs) ANNUAL REPORT ­ GUARDIANSHIP OF A MINOR Probate Rule 15(d) AS 13.26.070(4) & 13.06.100

Information About Minor
1. Housing. a. Where does the minor live now? Name of facility or place: Address: (street address) Type of Residence: private home b. Has the minor moved in the past year? (city) boarding school Yes No (state) (ZIP)

If yes, explain:

c. 2.

Minor's telephone number:

Medical and Psychological Care. a. Which of the following professionals has the minor seen in the past 12 months? Doctor's Name Phone No. Reason Seen Doctor

Dentist Eye Doctor Mental Health Professional Other:

b.

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

Page 2 of 5 PG-640 (10/06)(cs) ANNUAL REPORT ­ GUARDIANSHIP OF A MINOR

Probate Rule 15(d) AS 13.26.070(4) & 13.06.100

3.

School and Job Training. Does the minor attend school or any type of job training? Yes. Name of school: City: Grade: Describe the minor's school experience (grades, relationships, behavior):

No, because: 4. Work. Is the minor employed? No Yes. Describe (include type of work, name of employer, address, phone, and how long employed):

5.

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

b.

Have there been any other contacts? No Yes, as follows: Type of Contact Frequency of Contact by telephone by mail or e-mail through 3rd person: other: Describe the minor's contacts with the minor's parents:

c.

6.

City, State or Federal Agency Services. Does the minor receive services from any No Yes (describe below) government agency (city, state, or federal)? Services Received Agency Phone Name of Agency

Page 3 of 5 PG-640 (10/06)(cs) ANNUAL REPORT ­ GUARDIANSHIP OF A MINOR

Probate Rule 15(d) AS 13.26.070(4) & 13.06.100

7.

Significant Events. Describe any significant events affecting the minor that have occurred during the past 12 months:

8.

Minor's Income and Assets. a. Has a separate conservator been appointed for the minor? Name of conservator: No Yes

b.

Describe any income received by the minor in the past 12 months. Include earned income, investment income, government benefits, insurance proceeds, etc. List the source and the amount:

c.

Did the minor receive an Alaska Permanent Fund Dividend? If yes, how was the money spent or invested?

Yes

No

d.

Do you receive child support from the minor's parents? Yes, $ per month. No Does the minor have health insurance (from Denali KidCare or another policy)? Yes (describe): No Is there a bank savings account for the minor? If yes, what bank: Yes No Balance $

e.

f.

g.

Other savings, investment, or checking accounts for the minor. Name of Financial Institution Balance in Minor's Account

Page 4 of 5 PG-640 (10/06)(cs) ANNUAL REPORT ­ GUARDIANSHIP OF A MINOR

Probate Rule 15(d) AS 13.26.070(4) & 13.06.100

h.

Trusts. Is the minor a beneficiary of any trusts (meaning the minor has the right to receive benefits of some kind from the trust)? No Yes Name of Trust: Name and Address of Trustee: Other Assets. List other valuable assets that belong to the minor (for example: motor vehicles, Native Corporation stock, fishing permits, etc.):

i.

j.

Are there any pending lawsuits involving the minor? If yes, describe:

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____. (SEAL)

Guardian's Signature , Alaska

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

Page 5 of 5 PG-640 (10/06)(cs) ANNUAL REPORT ­ GUARDIANSHIP OF A MINOR

Probate Rule 15(d) AS 13.26.070(4) & 13.06.100