GUARDIAN'S REPORT/ GUARDIANSHIP OF PERSON WITH INTELLECTUAL DISABILITY PC-771 REV. 10/11 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.] TO: COURT OF PROBATE, DISTRICT NO. IN THE MATTER OF [Name, permanent address, and zip code.] WARD'S DATE OF BIRTH 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 PRESENT ADDRESS OF WARD [If institutionalized, give name and address of institution.] to and is being filed for the Plenary Guardian/Limited Guardian has resigned or has been removed. Court-ordered Report Significant change in the ward's capacity to meet the essential requirements for physical health or safety 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: continued modified terminated. Give reasons for your answer: .............................................................................................. Plenary Guardian's/Limited Guardian's Signature Print Name: Dated at: ............................................................................................... Plenary Guardian's/Limited Guardian's Signature Print Name: ,Connecticut, on [Month, Day, Year] GUARDIAN'S REPORT/GUARDIANSHIP OF PERSON WITH INTELLECTUAL DISABILITY PC-771 American LegalNet, Inc. www.FormsWorkFlow.com