Free Annual Guardian Report - Oregon

IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINN

IN THE MATTER OF THE GUARDIANSHIP OF :

) ) ________________________________, a protected person. )

Case Number: _________________

GUARDIAN'S REPORT I am the guardian for the protected person named above, and I make the following report to the court as required by ORS 125.325: 1. 2. 3. 4. 5. 6. My name is: ________________________________________________________________________ My address and telephone numbers are: __________________________________________________ The name (if applicable) and address of the place where the protected person now resides are: __________________________________________________________________________________ The protected person is currently residing at the following type of facility or residence: __________________________________________________________________________________ The protected person is currently engaged in the following programs and activities and receiving the following services: __________________________________________________________________ I was paid for providing the following items of lodging, food, or other services to the protected person: ___________________________________________________________________________ The person(s) primarily responsible for the care of the protected person at the protected person's place of residence is/are: _____________________________________________________________ The name and address of any hospital or other institution where the protected person is now admitted on a temporary or permanent basis is: __________________________________________________ The protected person's physical condition is as follows: ____________________________________ The protected person's mental condition is as follows: _____________________________________ I made the following contacts with the protected person during the past year: __________________ __________________________________________________________________________________ I made the following major decisions on the protected person's behalf during the past year: __________________________________________________________________________________ I believe the guardianship (should/should not) continue because: ____________________________ __________________________________________________________________________________ At the time of my last report, I held the following amount of money on behalf of the protected person: $___________. Since my last report, I have received the following amount of money on behalf of the protected person: $_____________. I spent the following amount of money on behalf of the protected person: $___________. I now hold the following amount of money on behalf of the protected person: $__________. (Attach itemized list of receipts and expenditures).

7.

8. 9. 10. 11. 12. 13.

14.

15. 16.

A true copy of this report will be given to the protected person, any conservator for the protected person, and any other person who has requested notice. Since my last report: (a) I have been convicted of the following crimes (not including traffic violations) : _____________ _______________________________________________________________________________ (b) I have filed for or received protection from creditors under the Federal Bankruptcy Code (yes or no) : __________ (c) I have had a professional or occupational license revoked or suspended (yes or no) : _________ (d) I have had my driver's license revoked or suspended (yes or no) : ________________________

17.

Since my last report, I have delegated the following powers over the protected person for the following periods of time (provide name of person and powers delegated) : __________________ ___________________________________________________________________________________

I hereby declare that the above statements are true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury.

Dated this ______ day of __________________, 20___. _____________________________________________ Guardian's signature STATE OF OREGON ) County of Linn ) I, _____________________________, being first duly sworn, say that the above statements are true: (print name) _____________________________________________ Guardian signature SUBSCRIBED AND SWORN TO before this ______ day of ___________________, 20___. _____________________________________________ Notary Public for Oregon/Court Clerk My commission expires:________________ ******************************************************************************************

Guardian's Report approved this _____ day of _________________, 20___. ______________________________________ Circuit Judge

MyFiles/Probate/GuardianReport02/08