Probate Rule 15(d) AS 13.26.167(4) & 13.06.100 Page 1 of 5 PG-640 ()(cs) ANNUAL REPORT GUARDIANSHIP OF A MINOR IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Protective Proceedings of: ) Name of Minor: ) ) CASE NO. Date of Birth: ) ) 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 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 minorcurrent situation and what has happened in the last 12 months. You must file a report every Reporting Period This report covers the following period: From To Information About Guardian Daytime Phone 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) (city) (state) Do you live with the minor? Yes No Relationship to minor: Changes in Guardianship Needed Should any changes be made in the guardianship? No Yes If yes, explain: If you want the court to change its order, please file form PG-190. Probate Rule 15(d) AS 13.26.167(4) & 13.06.100 Page 2 of 5 PG-640 ()(cs) ANNUAL REPORT GUARDIANSHIP OF A MINOR Information About Minor 1.Housing.a.Where does the minor live now? Name of facility or place: Address: (street address) (city) (state) (ZIP) Type of Residence: private home boarding school b.Has the minor moved in the past year? Yes No If yes, explain: c. 2.Medical and Psychological Care.a.Which of the following professionals has the minor seen in the past 12 months? Phone No. Reason Seen Doctor Dentist Eye Doctor Mental Health Professional Other: b.Describe any significant medical problems (physical or mental) the minor has, anddescribe what is being done or will be done about them: American LegalNet, Inc. www.FormsWorkFlow.com Probate Rule 15(d) AS 13.26.167(4) & 13.06.100 Page 3 of 5 PG-640 ()(cs) ANNUAL REPORT GUARDIANSHIP OF A MINOR 3.School and Job Training.Does the minor attend school or any type of job training? Yes. Name of school: City: Grade: 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 ContactFrequency of Contact by telephone by mail or e-mail through 3rd person: other: c.Describe the minorminor 6.City, State or Federal Agency Services. Does the minor receive services from anygovernment agency (city, state, or federal)? No Yes (describe below) Name of Agency Services ReceivedAgency Phone American LegalNet, Inc. www.FormsWorkFlow.com Probate Rule 15(d) AS 13.26.167(4) & 13.06.100 Page 4 of 5 PG-640 ()(cs) ANNUAL REPORT GUARDIANSHIP OF A MINOR 7.Significant Events.Describe any significant events affecting the minor that have occurred during the past12 months: 8.Minor and Assets. a.Has a separate conservator been appointed for the minor? No Yes Name of conservator: b.Describe any income received by the minor in the past 12 months. Include earnedincome, investment income, government benefits, insurance proceeds, etc. List thesource and the amount: c.Did the minor receive an Alaska Permanent Fund Dividend? Yes No If yes, how was the money spent or invested? d. Yes, $ per month. No e.Does the minor have health insurance (from Denali KidCare or another policy)? Yes (describe): No f.Is there a bank savings account for the minor? Yes No If yes, what bank:Balance $ g.Other savings, investment, or checking accounts for the minor. Name of Financial Institution American LegalNet, Inc. www.FormsWorkFlow.com Probate Rule 15(d) AS 13.26.167(4) & 13.06.100 Page 5 of 5 PG-640 ()(cs) ANNUAL REPORT GUARDIANSHIP OF A MINOR h.Trusts. Is the minor a beneficiary of any trusts (meaning the minor has the right toreceive benefits of some kind from the trust)? No Yes Name of Trust: Name and Address of Trustee: i.Other Assets. List other valuable assets that belong to the minor (for example:motor vehicles, Native Corporation stock, fishing permits, etc.): j.Are there any pending lawsuits involving the minor? Yes No If yes, describe: 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 Signature Subscribed and sworn to or affirmed before me at , Alaska on , 20 . (SEAL) Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: Certificate of Service I certify that on (date) a copy of this report was mailed hand delivered to: [ist everyone served and attach extra pages if necessary]: Your signature: American LegalNet, Inc. www.FormsWorkFlow.com