CONNECTICUT PROBATE COURTS Guardian222s Report/ Guardianship of Person With Intellectual Disability PC - 771 REV. 1/1 9 CONFIDENTIAL Guardian222s Report/ Guardianship of Person with Intellectual Disability PC - 771 Page 1 of 2 RECEIVED : Instructions: 1) A guardian of the person of an adult with intellectual disability may use this form to report to the Probate Court at least annually on the condition of the person under guardianship. 2) The guardian should respond to every question. If a question does not apply, the may indicate 223Not Applicable224 or 223N/A.224 3)For more information, see C.G.S. sections 45a-677 (f) and 45a-681 (c).4)Type or print the form in ink. Use a separate sheet, or PC-180, Second Sheet, if more space is needed.Probate Court Name District Number In the Matter of Herein a fter referred to a s the protected person Present Address and Telephone Number of the Protected Person Plenary/Limited Guardian of the Person (Name, address and telephone number of each guardian) Standby Plenary/Limited Guardian of the Person (Name, address and telephone number of each guardian) The guardian222s report is being filed for the following reason: Annual report Significant change in protected person222s capacity to meet essential requirements for physical health or safety Court-ordered report Plenary/Limited guardian has resigned or been removed Statutory review of guardianship The guardianship has been terminated. Please respond to the following questions for the period since the last guardian222s report was filed in court, or if this is the first report, since your appointment as guardian. 1.Describe the significant changes in the capacity of the protected person to meet the essential requirements forphysical health or safety. 2. List the services being provided to the protected person. Indicate whether they meet the protected persons222 needs and the relationship of the services to the individual guardianship plan. American LegalNet, Inc. www.FormsWorkFlow.com CONNECTICUT PROBATE COURTS Guardian222s Report/ Guardianship of Person With Intellectual Disability PC - 771 REV. 1/1 9 CONFIDENTIAL Guardian222s Report/ Guardianship of Person with Intellectual Disability PC - 771 Page 2 of 2 3. Describe any significant actions you have taken regarding the protected person . 4. Describe any significant problems that have ari sen relating to the guardian ship. 5. List any other factors that you believe should be considered by the Probate Court. In my opinion, the guardianship should be continued modified terminated. State reason for your answer: Signature of Guardian of the Person Type or Print Name Date Signature of Guardian of the Person Type or Print Name Date American LegalNet, Inc. www.FormsWorkFlow.com