IN THE CIRCUIT COURT FOR HILLSBOROUGH COUNTY, STATE OF FLORIDA, GUARDIANSHIP, PROBATE AND MENTAL HEALTH DIVISION IN RE: THE GUARDIANSHIP OF CASE NO.: _____-CP-_________ ______________________________________ (Name) DIVISION: __________________ ANNUAL GUARDIANSHIP PLAN (GUARDIANSHIP REPORT) OF GUARDIAN OF PERSON (adult) If limited guardianship, check rights which were removed: __to marry __to contract __to vote __to determine residency __to apply for gov't benefits __choose social environment __to sue/defend __to gift __consent to treatment __to travel __driver's license __seek employment ________________________, the guardian of the person of _______________________ (the ward), submits the following plan as the Annual Guardianship Plan of this guardian: The Annual Guardianship Plan for the period beginning ___________________, 20___, and ending __________________, 20 _____, shall be as follows: The ward's address at the time of filing this plan is: 1. 2. During the preceding year, the ward was maintained at (include dates, names, addresses and length of stay at each place; include date ward began residing at this address and date left {if applicable}; name{s} of caregiver/relative with whom the ward resides and the physical address of the location. Also include a statement as to why this is the best living arrangement for the ward): 1 American LegalNet, Inc. www.FormsWorkFlow.com 3. Plans for ensuring that the ward is in the best residential setting to meet the ward's needs during the coming year are as follows (What will the guardian do to ensure the ward is in the most appropriate living arrangement? For example, will the guardian attend care plan meetings, visit with the ward, confer with caregivers/medical professionals, etc.): 4. The following is a resume of any medical treatment given to the ward during the preceding year (the guardian must detail all medical and mental health providers the ward visited and the reasons for these visits during the past year): 5. Attached is a report of a physician who examined the ward no more than ninety (90) days before the beginning of the report period containing that physician's evaluation of the ward's condition, a statement of the current level of capacity of the ward and a statement of whether a guardian is still necessary. The report must be signed by a licensed physician, preferably the ward's primary care physician, psychiatrist, or a neurologist. Forms signed by an ARNP will not be accepted, absent a change in the current law. 2 American LegalNet, Inc. www.FormsWorkFlow.com 6. The plan for providing medical, mental health and rehabilitative services in the coming year is as follows (what doctors or other medical/mental health providers does the guardian expect the ward to visit in the upcoming year): 7. ward: The following information is submitted concerning the social condition of the a.) The social and personal services currently used by the ward are as follows (The guardian must detail all services provided to, or for, the ward, including any services provided by friends, family, paid caregivers or facility staff. In addition, the guardian must explain how the ward spends his/her day.): b.) The following is a statement of the social skills of the ward, including how well the ward communicates and maintains interpersonal relationships (Does the ward communicate verbally? How does he/she communicate his/her wants or needs?): 3 American LegalNet, Inc. www.FormsWorkFlow.com c.) The social needs of the ward (What does/would the ward require to obtain/maintain social happiness and interaction?): 8. The following is a summary of activities during the preceding year designed to enhance the capacity of the ward (What has the guardian done to maintain or increase the ward's quality of life?): 9. Is the ward now capable of having some or all of the ward's rights restored? If so, identify the rights that should be restored. (The guardian's statement should agree with the physician's statement. If it does not, an explanation should be provided.) 10. Do you plan to seek the restoration of any rights to the ward? (If the guardian believes the ward should have rights restored, the guardian should describe his/her efforts to have the rights restored.) 4 American LegalNet, Inc. www.FormsWorkFlow.com 11. This plan has/has not (circle one) been reviewed with the ward. If this is a limited guardianship, the guardian must review the plan with the ward, and provide the ward with a copy of the plan, pursuant to F.S. §744.367(3). Under penalties of perjury, I declare that I have read the foregoing and the facts alleged are true, to the best of my knowledge and belief. Signed on________________________, 20____. __________________________ Attorney for Guardian Print Name: _______________ Florida Bar No. ____________ Address: __________________ __________________________ Phone Number: (___) ___-____ Email Address: ___________________________ __________________________ Guardian Print Name: _______________ Address: __________________ __________________________ Phone Number: (___) ___-____ Email Address: ___________________________ REMEMBER CERTIFICATE OF SERVICE: *On Ward, if a Limited Guardianship *Any Interested Persons/Parties 5 American LegalNet, Inc. www.FormsWorkFlow.com