Free PC-771 - Connecticut

GUARDIAN'S REPORT/ GUARDIANSHIP OF PERSON WITH MENTAL RETARDATION PC-771 REV. 10/05

STATE OF CONNECTICUT
RECORDED (CONFIDENTIAL VOLUME):

COURT OF PROBATE [Type or print in black ink.] [Use back of form or additional sheets if more space is required.] DISTRICT NO.
WARD'S DATE OF BIRTH

TO: COURT OF PROBATE, DISTRICT OF IN THE MATTER OF [Name, permanent address, and zip code.]

PRESENT ADDRESS OF WARD [If institutionalized, give name and address of institution.]

Hereinafter referred to as the ward. PLENARY GUARDIAN(S)/LIMITED GUARDIAN(S) OF THE PERSON [Name(s), address(es), zip code(s) and telephone number(s)]

STANDBY PLENARY GUARDIAN(S)/LIMITED GUARDIAN(S) OF THE PERSON [Name(s), address(es), zip code(s) and telephone number(s)]

This guardian's report covers the reporting period from following reason: [C.G.S. §§45a-677(f), 45a-681(c)] Annual Report Court-ordered Report Significant change in the ward's capacity to meet the essential requirements for physical health or safety

to

and is being filed for the

Plenary Guardian/Limited Guardian has resigned or has been removed. Application for termination of the guardianship has been filed.

PLEASE PROVIDE THE FOLLOWING INFORMATION. BE AS SPECIFIC AS POSSIBLE. List significant changes in the capacity of the ward to meet the essential requirements for physical health or safety.

List the services being provided to your ward. Indicate whether they meet the ward's needs as outlined in the individual guardianship plan.

List all significant actions you have taken regarding your ward since your last report.

List all significant problems regarding this guardianship that have arisen since your last report.

List any other factors that you believe should be considered by the Court.

In your opinion, the guardianship should be: Give reasons for your answer:

continued

modified

terminated.

.............................................................................................. Plenary Guardian's/Limited Guardian's Signature Print Name: Dated at: ,Connecticut, on [Month, Day, Year]

............................................................................................... Plenary Guardian's/Limited Guardian's Signature Print Name:

GUARDIAN'S REPORT/GUARDIANSHIP OF PERSON WITH MENTAL RETARDATION PC-771 RESET