Name of Guardian Address City, State, Zip Code Telephone Number IN THE FAMILY COURT OF THE FIRST CIRCUIT037 STATE OF HAWAI221I 037In the Matter of the Guardianship of ) ) FC-G No. ) INITIAL REPORT OF THE GUARDIAN ) OF AN INCAPACITATED PERSON; (Full Legal Name) , ) ) NOTICE OF THE FILING OF INITIAL REPORT An Incapacitated Person.036 ) ) INITIAL REPORT OF THE GUARDIAN OF AN INCAPACITATED PERSON 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.036 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. INITIAL REPORT OF THE GUARDIAN FC Adm 3/4/14 PAGE 1 OF 5 PAGES OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com b. Guardian222s Name Date Appointed Residence Address, City, State, Zip Code Mailing Address, City, State, Zip Code Home Phone No.036 Business Phone No. 2.037 RESIDENTIAL ARRANGEMENTS (if Ward is living with other than Guardian) 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 of037 the Ward)037 4.037 FINANCIAL SITUATION A. Was a Conservator (other than yourself) appointed by the First Circuit Court,037 State of Hawai221i, to manage Ward222s financial affairs? ~Yes ~No037 Name of Conservator036 Phone No. FC Case No. INITIAL REPORT OF THE GUARDIAN FC Adm 3/4/14 PAGE 2 OF 5 PAGES OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com 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), presently in the Guardian222s possession or subject to the Guardian222s control, as of thirty days after the guardianship appointment: 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 Guardian222s Signature Date Return completed form to: Attention: Office of the Chief Court Administrator Ronald T.Y. Moon Kapolei Courthouse 4675 Kapolei Parkway Kapolei, Hawai221i 96707 INITIAL REPORT OF THE GUARDIAN FC Adm 3/4/14 PAGE 3 OF 5 PAGES OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com IN THE FAMILY COURT OF THE FIRST CIRCUIT037 STATE OF HAWAI221I 037In the Matter of the Guardianship of ) ) FC-G No. ) NOTICE OF THE FILING OF INITIAL (Full Legal Name) ) , ) ) REPORT An Incapacitated Person.036 ) ) NOTICE OF FILING OF INITIAL REPORT STATE OF HAWAI221I037 TO:037 Name and Address:037 Name and Address: Name and Address: Name and Address: Name and Address: Name and Address: INITIAL REPORT OF THE GUARDIAN FC Adm 3/4/14 PAGE 4 OF 5 PAGES OF AN INCAPACITATED PERSON American LegalNet, Inc. www.FormsWorkFlow.com Notice is hereby given that has submitted the attached Initial 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 INITIAL REPORT OF THE GUARDIAN FC Adm 3/4/14 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 Initial 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 INITIAL REPORT ,)037 (Full Legal Name) )037 An Incapacitated Person.036 )037 )037 NOTICE OF FILING OF INITIAL 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 initial report and notice to other people, list their names and addresses here. Notice is hereby given that (Name of Guardian) has submitted the attached Initial 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 3/4/14036 SAMPLE - Instruction Sheet American LegalNet, Inc. www.FormsWorkFlow.com