My Name: Co-Guardian's Name: Mailing Address: City, State, Zip: Phone Number: Representing Self IN THE SUPERIOR COURT OF ARIZONA, COUNTY OF COCONINO In the Matter of the Guardianship and/or Conservatorship of: Case Number: GC GUARDIAN'S REPORT Name of Ward 1: Name of Ward 2: Name of Ward 3: [ ] An Adult [ ] A Minor NOTICE OF HEARING: Fill out the "Notice of Hearing" section only if this is an Annual Report. The court has set a hearing to review this Report as follows: Date: Time: Division: (All Divisions are in the Coconino County Courthouse, 200 N. San Francisco St., Flagstaff, AZ.) Unless it is on the non-appearance calendar, the guardian shall appear at the hearing. Anyone else with an interest in this case needs to appear at the hearing only if they want to object to part of this Report. If you know in advance that you can't attend the hearing on the date scheduled, you may ask the court to reschedule, or "continue", the hearing. Asking for a continuance involves multiple steps and deadlines that the court will expect you to know and follow. See the Self-Help Center packet Moving a Court Date to a Later Date. GUARDIAN'S REPORT: Report Period Opening Date: Closing Date: Closing Date Enter the date nine months from the Opening Date Enter the date one year from the Opening Date Enter the date you fill out this form [ ] ANNUAL REPORT AND NOTICE OF HEARING [ ] On the non-appearance calendar [ ] REPORT UPON DISCHARGE For an Annual Report: For a Report Upon Discharge: Opening Date If this is the first Report: Enter the date the judge signed the Order Appointing a Guardian and/or Conservator If this is not the first Report: Enter the Closing Date of the last Report Enter the Closing Date of the last Report Page 1 of 4 Revised December 2010 Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkFlow.com The Ward: Ward 1's Age: Ward 2's Age: Ward 3's Age: Birthdate: Birthdate: Birthdate: Year Minor Will Turn 18: Year Minor Will Turn 18: Year Minor Will Turn 18: The Guardian and/or Conservator: NAME: Phone: Street Address: City, State, Zip: NAME: Phone: Street Address: City, State, Zip: [ ] True or [ ] False: The guardian has been charged with or convicted of a criminal offense, other than a civil traffic violation, during this report period. If True, explain: Court: Case Number: Charge: Where the Ward Lives: The information about where the ward lives [ ] changed or [ ] did not change during this report period. If it changed, enter the new information: Ward's Address: Phone Number: The ward lives in the private home of: The ward lives in the following facility: Facility Type: Address: Governmental Agency Services: The ward received services from the following governmental agency: AGENCY'S NAME: Person Responsible for the Ward's Affairs at the Agency: Summary of Services: AGENCY'S NAME: Person Responsible for the Ward's Affairs at the Agency: Summary of Services: Certificate of Delivery: I will mail or hand-deliver a copy of this Report to the following people on the day I file it: Person in Charge of Facility: Page 2 of 4 Revised December 2010 Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkFlow.com Enter the name and address of each person listed on the Petition for Guardianship and/or Conservatorship under "People Entitled to Notice". If any person listed can't be found, enter that person's last address listed in the court file. If that person has no address in the court file, do not list that person. Also enter the name and address of 1) any guardian other than you and 2) any courtappointed attorney of the ward. WARD 1 THE WARD OVER 13 NAME: Street Address: City, State, Zip: THE WARD'S MOTHER NAME: Street Address: City, State, Zip: THEIR FATHER NAME: Street Address: City, State, Zip: THEIR CLOSEST ADULT RELATIVE NAME: Street Address: City, State, Zip: THEIR COURT-APPOINTED ATTORNEY NAME: Street Address: City, State, Zip: THEIR CONSERVATOR NAME: Street Address: City, State, Zip: NAME: Street Address: City, State, Zip: PEOPLE HAVING CARE OR CUSTODY OF THEM NAME: Street Address: City, State, Zip: NAME: Street Address: City, State, Zip: THE WARD'S SPOUSE: NAME: Street Address: City, State, Zip: PEOPLE WHO FILED A DEMAND FOR NOTICE NAME: Street Address: City, State, Zip: NAME: Street Address: City, State, Zip: WARD 2 WARD 3 THE WARD'S ADULT CHILDREN Page 3 of 4 Revised December 2010 Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkFlow.com Contact Between the Ward and the Guardian: Number of Times I've Seen the Ward in the Last 12 Months: Date I Last Saw the Ward: The Ward's Physician: Physician's Name: Address: Date a Physician Last Saw the Ward: A copy of the physician's report is attached. Inpatient Mental Health Care Authority: If I have inpatient mental health care authority, a report by a psychiatrist or psychologist explaining whether the ward currently needs inpatient mental health care and treatment is attached. The Ward's Status: Major changes in the ward's physical or mental condition during the report period: Why the guardianship should continue or change: Anything Else I Want the Court to Know: My Signature Date: Co-Guardian's Signature Date: Page 4 of 4 Revised December 2010 Coconino County Law Library and Self-Help Center Forms American LegalNet, Inc. www.FormsWorkFlow.com