FOR CLERK’S USE ONLY Name of Person Filing: _______________________________________ Mailing Address: _______________________________________ City, State, Zip Code: _______________________________________ Day/Evening Telephone: _______________________________________ ATLAS Number (if applicable) _______________________________________ Attorney Bar Number (if applicable) __________________________________ Representing: Self Petitioner Respondent SUPERIOR COURT OF ARIZONA MOHAVE COUNTY In the Matter of the Guardianship of Case No. __________________________ ANNUAL REPORT OF GUARDIAN ____________________________________ An Incapacitated and/or Protected Person Pursuant to A.R.S. § 14-5315 for an adult, _________________________, Guardian for an incapacitated person, submits the Annual Guardianship Report and Physician’s Report. A copy of this report shall be forwarded to those persons set forth in A.R.S. § 14-5315(B). PERIOD FROM:_______________ Month / Day / Year TO:_______________ Month / Day / Year , DUE:_______________ Month / Day / Year I am the guardian and make these statements: 1. Information about the Ward. Ward’s Name: _______________________________________________________________________ Ward’s Date of Birth:____________________________________________________________________ Ward’s Address: _________________________________________________________________ Ward’s Telephone: _________________________________________________________________ Residential situation (private home, boarding home, nursing home, etc.) _____________________________________________________________________________________ 2. Information about person in charge of home or facility. Name:________________________________________________________________________________ Facility:_______________________________________________________________________________ Address:______________________________________________________________________________ Telephone:____________________________________________________________________________ 3. Information about the Ward’s Doctor. Ward’s Current Doctor: _________________________________________________________________ Doctor’s Address: _________________________________________________________________ Doctor’s Telephone Number:______________________________________________________________ 11/27/07 Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com Case No._______________________________ 4. Information about the Ward’s Physical and mental health. A. Date the Ward was last seen by a doctor:_____________________________________________ B. Major changes in the Ward’s physical and/or mental condition in the last year as observed by the guardian: ______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ C. 5. Physician’s report is attached as Exhibit “A”. Information about the Ward’s Guardian. Guardian’s Name: ______________________________________________________________________ Guardian’s Address: ____________________________________________________________________ Guardian’s Telephone: __________________________________________________________________ 6. Information about the Guardianship. Number of times the Guardian has seen the Ward in the last 12 months:____________ Date of last visit: ______________. The Guardian’s opinion about whether the guardianship should continue: (Explain.) _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ 7. Information about the person responsible for managing the Ward’s assets: Person responsible for managing Ward’s assets: Name: _______________________________________________________________________________ Address: _____________________________________________________________________________ Telephone Number: ____________________________________________________________________ 8. Summary of governmental services provided to the ward and individual responsible for ward’s affairs with that agency: _______________________________ ______________________________ Services provided Agency/Individual _______________________________ ______________________________ Services provided Agency/Individual _______________________________ ______________________________ Services provided Agency/Individual Respectfully submitted this ___________ day of _______________, 20____. _____________________________________ Print Guardian’s Name 11/27/07 _________________________________ Signature of Guardian Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com Case No.________________________________ 10. AFFIDAVIT OF MAILING: Under penalty of perjury, I state to the Court that I have mailed or will mail a copy of this Annual Report of Guardian to the following people at the following address(es) on this date: ________________ (Month / Day / Year) • Name: ________________________________________________________________________ Address: ________________________________________________________________________ City, State, Zip Code________________________________________________________________ • Name: ________________________________________________________________________ Address: ________________________________________________________________________ City, State, Zip Code________________________________________________________________ • Name: ________________________________________________________________________ Address: ________________________________________________________________________ City, State, Zip Code________________________________________________________________ • Name: ________________________________________________________________________ Address: ________________________________________________________________________ City, State, Zip Code________________________________________________________________ 11. 11/27/07 Signature of person mailing the document __________________________________________________ Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com