II-M Superior Court of the District of Columbia PROBATE DIVISION In re: Intervention Proceeding No. _______________ _________________________________________ An Adult REPORT OF GUARDIAN ( ) I, the undersigned, represent that I am the guardian of the above named ward, and that my report to the Court is as follows: 1. Present age of ward:__________ Date of birth:__________ 2. Current address of ward: 3. Ward’s residence is: [ ] own home [ ] nursing home [ ] foster or boarding home [ ] guardian’s home [ ] hospital or medical facility [ ] relative’s home _____________ (relationship) [ ] other:______________ 4. Ward has been in present residence since________________ (date) State reasons for any change of residence within the past reporting period: ______________________________________________ ___________________________________________________ 5. During the past reporting period , I visited the ward _________ times. The date of the last visit was ______________. (date) American LegalNet, Inc. www.USCourtForms.com 6. During the past reporting period the ward’s mental health has: [ ] remained about the same. [ ] improved. (Describe:) ______________________________________________ ________________________________________________________________ [ ] deteriorated. (Describe:) 7. During the past reporting period the ward’s physical health has: [ ] remained the same. [ ] improved. (Describe:)______________________________________________ _______________________________________________________________ ________________________________________________________________ [ ] deteriorated. (Describe:) ____________________________________________ _______________________________________________________________ 8. During the past reporting period the ward has been treated or evaluated by the following: Physician. Name: __________________________________________ Address: __________________________________________ __________________________________________ Psychiatrist. Name: ___________________________________________________ Address: ___________________________________________ ___________________________________________ Social or other Case Worker Name: ___________________________________________ Address: ___________________________________________ ___________________________________________ Other. Name: ____________________________________________ Address: ____________________________________________ ____________________________________________ 9. Is the ward under a regular physician’s care? [ ] Yes [ ] No If yes, doctor’s name and address:_____________________________________ ________________________________________________________________ ________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com 10. Describe activities in which the ward has participated during the past reporting period: Recreational:______________________________________________________ Educational:________________________________________________________ Social:___________________________________________________________ Occupational:______________________________________________________ Other:____________________________________________________________ [ ] None available [ ] Refuses or unable to participate. 11. As guardian, I rate the ward’s living arrangements as: [ ] Excellent [ ] Average [ ] Below Average. (Explain:) _______________________________________________________________ _______________________________________________________________ 12. As guardian, I believe the ward is: [ ] Content with living situation. [ ] Unhappy with living situation. 13. As guardian, I believe the ward has the following unmet needs: _____________________________________________________________________ _____________________________________________________________________ 14. In my opinion, this guardianship [ ] should be continued [ ] should not be continued. (If not, explain:)_______________________________ _____________________________________________________________________ _____________________________________________________________________ 15. If I have been appointed limited guardian, my powers should be [ ] increased [ ] decreased. (Explain:)________________________________ American LegalNet, Inc. www.USCourtForms.com 16. I [ ] did [ ] did not have possession or control of any of the ward’s estate during the reporting period. If in possession or control of any of the estate, please indicate as follows: a. Total Amount Received and Source:_____________________________________ b. Total Amount Expended and for what purposes:____________________________ ___________________________________________________________________ c. Balance currently in my possession or control and location.___________________ ___________________________________________________________________ The undersigned swears 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. __________________ DATE _______________________________________ Signature of Guardian _______________________________________ Address of Guardian ______________________________________ City, State, Zip Code ______________________________________ Telephone Number of Guardian VERIFICATION I_______________________________________, being first duly sworn, on oath, (name of guardian) depose and say that I have read the foregoing pleadings by me subscribed and that the facts therein stated are true to the best of my knowledge, information and belief. _____________________________________ (Signature of Guardian) Subscribed and sworn to before me this______day____________________,20__ __________________________________ (Notary Public) CERTIFICATE OF SERVICE I hereby certify that on the______day of____________________20______, a copy of the foregoing Guardianship Report was served by first class mail, postage prepaid, upon the following parties to the above captioned case and persons granted permission to participate pursuant to SCR-PD 303 and persons who requested notice pursuant to SCR-PD 304. ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ American LegalNet, Inc. www.USCourtForms.com –5– American LegalNet, Inc. www.USCourtForms.com