Rev . 0 6 / 20 1 8 Page 1 of 3 IN THE COURT OF CHANCERY FOR THE STATE OF DELAWARE , C.M.# A p erson with a d isability Date of birth: ANNUAL UPDATE & MEDICAL STATEMENT Qtr Order Date If the date of th e final order appointing you as guardian (s) Due Date Statement is due every year by 1 st January 1 st to March 31 st January 1 st 2 nd April 1 st to June 30 th April 1 st 3 rd July 1 st to September 30 th July 1 st 4 th October 1 st to December 31 st October 1 st 1. Name of guardian(s): 2. Date guardian(s) was/were appointed: 3. List mailing address(es) for all guardian(s) : 4. List te lephone number(s) for all guardian(s) : 5. Print clearly the current e - mail add ress (es) for guardian(s) : 6 . C urrent residence and phone number of person with a di sability : What type of facility does the person with a disability reside? Foster home h ome Group h ome Nursing home State facility Their own home Other (specify) : 7 . List name and phone number of group home coo rdinator or facility director, if applicable: 8 . If there has been a change in residence since the last revie w, please identify the reason for the change: 9 . If the person with a disability does not reside in your home, please i ndicate approximately how often you see the person with a disability each month: American LegalNet, Inc. www.FormsWorkFlow.com Rev . 0 6 / 20 1 8 Page 2 of 3 10 . Identify any changes in the physical or mental condition of the person with a dis ability since the last review: 11 . Identify any governme ntal agencies or non - profit agencies that provide services, care, treatment, or otherwise are involved with the person with a disability ( e.g. DDDS, Chimes, Easter Seals) : 1 2 . Describe the management of the financial affairs of the person with a disability and identify any changes since the last review : 1 3 . If the g uardian(s) do(es) not manage the financial affairs of the person with a disability, who does? 1 4 . Have you explored whether t he person with a disabilit y qualifies for assistance programs such as Social Security, Medicare, Medicaid, SSI, Food Stamps, or Vetera and identify the benefits the person with a disability receives: 1 5 . Identi fy any information regarding the relationship the person with a disability has with family or interested parties that may be important in the event that additional or successor guardians seek to be appointed: 1 6 . Identify any problems or concerns that have arisen since the last review that you believe may limit your ability to continue to serve as guardian: 1 7 . Identify any other matters relating to this guardianship of which the Court should be aware : 1 8 . Is the person with a disability under a permanent disability? Yes No 1 9 . If the answer to Question 1 8 is No, explain why there is a continuing need for guardianship : Date e Date Co - NOTE: If more than one guardian has been appointed, only one guardian is required to sign this form. If preferred, all guardians may sign the form. American LegalNet, Inc. www.FormsWorkFlow.com Rev . 0 6 / 20 1 8 Page 3 of 3 MEDICAL STATEMENT ( T his portion of the form must be completed by a Doctor of Medicine, a Doctor of Osteopathic Medicine, a Physician Assistant, or an Advanced Practice Registered Nurse, actively licensed in the practice of medicine or surgery or the advanced practice of nursing in any jurisdiction in the United States of Americ a . ) I , , last examined name and title on the following date . Name of person with a disability Describe health of the p erson with a disability /diagnosis: Significant changes since last review: Hospitalizations/Surgical procedures since last review: Consequently, t here is a continued need for guardianship of the person with a disability : Yes No If No, why not? Date signature and title American LegalNet, Inc. www.FormsWorkFlow.com