Attorney’s Name: __________________________________ Computer Number: __________________________________ Party Name: __________________________________ Street Address: __________________________________ City, State, and Zip: __________________________________ Telephone Number: __________________________________ ARIZONA SUPERIOR COURT IN PIMA COUNTY IN THE MATTER OF: Case Number: Name: (from birth certificate) ___________________________________ Date of birth: ___________________________________ ANNUAL REPORT OF GUARDIAN FOR A MINOR CHILD A MINOR WARNING – READ AND SIGN By filing this Report with the court, you are stating under penalty of perjury that the statements contained in it are true to the best of your knowledge. If you state facts in this Report that you know to be false, you may be subject to serious penalties. Such penalties may include, but are not limited to, criminal prosecution for perjury, and/or a finding of criminal contempt. Perjury is a felony for which a term of four years in prison may be imposed. A person may be incarcerated for up to four months if found to be in criminal contempt of court. I, _______________________, have read the above warning, Signed: _______________________ Dated: _______________________ Page 1 of 5 American LegalNet, Inc. www.USCourtForms.com I, ___________________________ declare under oath and under penalty of perjury: 1. Describe the type of home or facility where the minor resides:   Private Residence Group Home (if so, describe and list the name of the home) ______________________________________________________ ______________________________________________________ What is the name of the person in charge of the residence or home? ______________________________________________________ What is the address of the residence or home? _____________________________________________________ _____________________________________________________ Who is the minor’s primary caregiver? _____________________________________________________ 2. How many times have you seen the minor in the last twelve months? ______ What date did you last see the minor? ____/____/_______ 3. List any major changes in the minor's development that you have observed in the last year: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 4. What is the name of the school the minor is currently attending? __________________________________________________________________ __________________________________________________________________ Describe the progress being made by the minor in school: __________________________________________________________________ __________________________________________________________________ Page 2 of 5 American LegalNet, Inc. www.USCourtForms.com 5. List the name, address and phone number of the minor's physician: Name: Address: Telephone: ____________________________ ____________________________ ____________________________ (_____)______________________ 6. What date was the minor last seen by a physician? ____/____/_______ 7. I have attached a copy of the following document from the minor’s physician:   Minor's physician's report to the guardian Statement containing the physician's observations on the minor's physical and mental health 8. List any major changes in the minor's physical or mental condition observed by you in the last year: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 9. Answer the following questions only if the minor is a disabled or incapacitated person: Will the minor reach the age of majority (18) during the coming year?  No  Do you believe that, because the minor is incapacitated, the guardianship should be continued after the minor becomes an adult? 10. Yes Yes  No  What services are being provided to the minor by a government agency? (Include any Social Security benefits paid on behalf of the minor): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Page 3 of 5 American LegalNet, Inc. www.USCourtForms.com List the name and title of the individual responsible for the minor's affairs with that agency: __________________________________________________________________ 11. List all persons, including any minors, who reside with the minor. If a minor residing in the household is also the subject of a guardianship, list the case number of the guardianship: Name: __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ Relationship: to minor __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ Case number (if applicable) __________________ __________________ __________________ __________________ __________________ __________________ __________________ __________________ 12. Has any person who resides with the minor ever been convicted of a felony, or adjudicated as a delinquent child? If so, explain. Provide the State and County where the offense was committed and the case number for the conviction. Provide the State, County, and Court where the adjudication of delinquency was made. ________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 13. Have any proceedings for adoption, custody, or dependency of this child been commenced within the preceding 12 months? If proceedings have been commenced, the guardian must provide the case number of the proceedings to this court. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 14. Is the minor enrolled in a health insurance plan or an equivalent program (such as AHCCCS) run by the state? __________________________________________________________________ Page 4 of 5 American LegalNet, Inc. www.USCourtForms.com 15. What efforts have you made to obtain child support from the child's parents, either in person or through a state agency? If a Title IV(D) case has been filed by the Attorney General, provide the case number of that case. __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 16. A copy of this report must be mailed to the following people at least nineteen (19) days before the hearing date. By providing the information below, you are swearing, under penalty of perjury, that the Annual Report of Guardian for a Minor was mailed to the following persons: Person Name Address Date of Mailing or Delivery The minor if over the age of 14 The minor's conservator The courtappointed attorney for the minor (if one has been appointed) The minor's parent or parents Any other interested person who has filed a demand for notice with the court I, the undersigned, swear or affirm that the answers set forth above are true and correct to the best of my knowledge and belief, subject to the penalties of making a false affidavit or declaration. DATED: _____________ ____________________________________ Guardian's name Mail original report to: Probate Clerk Arizona Superior Court in Pima County 110 W. Congress St., Tucson, AZ 85701 Page 5 of 5 American LegalNet, Inc. www.USCourtForms.com