Name of Guardian Address City, State, Zip Code Telephone Number IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI221I In the Matter of the Guardianship of ) ) ) ) (Full Legal Name) , ) ) An Incapacitated Person. ) ) FC-G No. ANNUAL REPORT OF THE GUARDIAN037 OF AN INCAPACITATED PERSON FOR037 TO037 ; NOTICE OF FILING OF ANNUAL REPORT ANNUAL REPORT OF THE GUARDIAN OF AN INCAPACITATED PERSON FOR TO Age of Incapacitated Person (Ward): 1. INFORMATION ON GUARDIAN(S) a. Guardian222s Name Date Appointed Residence Address, City, State, Zip Code Mailing Address, City, State, Zip Code Home Phone No. Business Phone No. In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if yourequire reasonable accommodation for a disability, please contact the ADA Coordinator at the First Circuit Family Courtoffice by telephone at 954-8200, fax 954-8308, or via email at adarequest@courts.hawaii.gov at least ten (10) working days prior to your hearing or appointment date. Please call the Family Court Service Center at 954-8290 if you have any questions regarding forms or procedures. ANNUAL REPORT OF THE GUARDIAN FC Adm 3/5/14 PAGE 1 OF 5 PAGES OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com B. Guardian222s Name036 Date Appointed Residence Address, City, State, Zip Code Mailing Address, City, State, Zip Code037 Home Phone No. Business Phone No.037 2.037 RESIDENTIAL ARRANGEMENTS (during the period covered by this Annual Report) Ward222s Residence Address, City, State, Zip Code036 Phone No. Caregiver222s Name036 Phone No. 3.037 PRESENT CONDITION OF THE WARD (Please describe the present condition of the Ward. 4.037 SERVICES PROVIDED TO THE WARD (Please provide the medical, educational, vocational, and other services provided to the Ward and your opinion as to the adequacy of the Ward222s care during the period covered by this Annual Report. Please include the Individualized Service Plan (ISP).) ANNUAL REPORT OF THE GUARDIAN FC Adm 3/5/14 PAGE 2 OF 5 PAGES OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com 5.037 SUMMARY OF GUARDIAN222S VISITS WITH WARD, ETC. (Please provide a summary of your visits with the Ward and activities on the Ward222s behalf and the extent to which the Ward has participated in decision-making.) 6.037 CURRENT PLAN FOR CARE, TREATMENT, OR HABILITATION (If the Ward is presently in an institution, is the current plan for care, treatment or habilitation in the Ward222s best interests?) 7.037 PLANS FOR FUTURE CARE (Please describe if there are any plans for future care.) 8.037 NEED FOR CONTINUED GUARDIANSHIP AND/OR ANY CHANGES: (Please provide your recommendation as to whether or not the guardianship needs to continue and if there are any recommended changes in the scope of the guardianship.) ANNUAL REPORT OF THE GUARDIAN FC Adm 3/5/14 PAGE 3 OF 5 PAGES OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com 9.FINANCIAL SITUATION036 A.036 Was a Conservator (other than yourself) appointed by the First Circuit Court, State of Hawai221i, to manage Ward222s financial affairs? ~Yes ~No Name of Conservator036 Phone No. FC Case No. B.036 Monthly income (incoming income received from Social Security, Pensions, retirement, etc. Do not include account numbers or social security numbers.) Source036 Amount Payee C.036 List assets (checking, savings, etc. - Do not include account numbers or social security numbers.) Provide balance and date: THE UNDERSIGNED SOLEMNLY AND SINCERELY DECLARES, UNDER PENALTY OF PERJURY, THAT THE STATEMENTS MADE HEREIN ARE COMPLETE, TRUE AND TO THE BEST OF HIS/HER KNOWLEDGE, INFORMATION AND BELIEF. FOR OFFICIAL USE Guardian222s Signature036 Date Date Reviewed Family Court Officer Return completed form to: Guardian222s Signature036 Date Date Report Due: Attention: Office of the Deputy Chief Court AdministratorRonald T.Y. Moon Kapolei Courthouse 4675 Kapolei Parkway Kapolei, Hawai221i 96707 ANNUAL REPORT OF THE GUARDIAN FC Adm 3/5/14 PAGE 4 OF 5 PAGES OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI221I In the Matter of the Guardianship of ) FC-G No. ) ) ) ,) (Full Legal Name) ) An Incapacitated Person. ) ) NOTICE OF FILING OF ANNUAL REPORT037 NOTICE OF FILING OF ANNUAL REPORT037 STATE OF HAWAI221I 037TO:037 Name and Address:037 Name and Address: Name and Address: Name and Address: Notice is hereby given that has submitted the attached Annual Report to the Family Court of the First Circuit and that copies will be forwarded to the above-named person(s) no later than fourteen (14) days after the date noted below. DATED: Kapolei, Hawai221i, . Signature of Guardian ANNUAL REPORT OF THE GUARDIAN FC Adm 3/5/14 PAGE 5 OF 5 PAGES OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com SAMPLE -Instruction Sheet for Completing the Notice of Filing of Annual Report IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI221I In the Matter of the Guardianship of036 ) FC-G No. 12-1-1234 ) ) NOTICE OF FILING OF ANNUAL REPORT ) ,)037 (Full Legal Name) )037 An Incapacitated Person.036 )037 )037 NOTICE OF FILING OF ANNUAL REPORT STATE OF HAWAI221I TO: Name and Address: John A. Doe 263 Sample name and address of Ward 1234 Silver Street Honolulu, Hawai221i 96800 Name and Address: your Order Appointing Guardian263263 If ordered you to give copies of the annual report and notice to other people, list their names and addresses here. Notice is hereby given that (Name of Guardian) has submitted the attached Annual Report to the Family Court of the First Circuit and that copies will be forwarded to the above-named person(s) no later than fourteen (14) days after the date noted below. DATED: Kapolei, Hawai221i, (date that Guardian mails this report to Family . (Guardian signs here) Signature of Guardian FC Adm 3/5/14036 SAMPLE - Instruction Sheet American LegalNet, Inc. www.FormsWorkFlow.com