Name Address Telephone IN THE FAMILY COURT OF THE SECOND CIRCUIT STATE OF HAWAII IN THE MATTER OF THE GUARDIANSHIP PERSONS NAME PERSONS BIRTHDATEFC-G NO. ANNUAL REPORT OF THE GUARDIAN (date) to (date) NOTICE OF FILING OF ANNUAL REPORT ANNUAL REPORT OF THE GUARDIAN DATE to ) ) ) ) ) ) ) ) : ) ) ; DATE 1.Information on Guardiana.002 Guardians Name Date Appointed002 Residence Address, City, State, Zip Code Mailing Address, City, State, Zip Code Home Phone No. Business Phone No. 1 American LegalNet, Inc. www.FormsWorkFlow.com b. Guardians Name Date Appointed Residence Address, City, State, Zip Code Mailing Address, City, State, Zip Code Home Phone No. Business Phone No. 2. Case manager/social worker Agency Phone No. RESIDENTIAL ARRANGEMENTS 3. Person=s Residence Address, City, State, Zip Code003 Phone No. Description (Circle one): Own home, guardian=s home, group home, foster home, care home, intermediate care facility, skilled nursing facility, hospital, other (identify): If moved since last report, state number of times and reasons: Caregiver=s name: PHYSICAL AND MENTAL CONDITION 4. 003 Physical health: Improved Declined Remained the same [ ] [ ] [ ] Mental health: [ ] Improved [ ] Declined [ ] Remained the same 2 American LegalNet, Inc. www.FormsWorkFlow.com 5. 003 Summary of professional medical and mental health treatment and evaluations. Include any hospitalizations and new diagnoses:Medications taken:Name of physician:002 Diagnosis: 002 Frequency of medication review by physician:002 6. 003 If person is in nursing f acility, please submit a copy of the annual Minimum Data Set (MDS). SOCIAL CONDITION 7. 003 Have there been any significant changes in persons ability to interact and get along withothers? [ ] Yes [ ] No. If yes, please explain: 8. 003 Participation in the following social/recreational activities: EDUCATIONAL AND TRAINING PROGRAM 9. 003 Identify program and describe persons adjustment and progress since last report: 10. Please attach copy of annual agency report and services plan [if applicable] FINANCIAL SITUATION 11. Medical Plan(s):12. Was a separate Guardian/Conservator of the Property (other than yourself) appointed by theSecond Judicial Circuit, State of Hawaii, to manage wards financial affairs?[ ]Yes [ ]No Name of Guardian of Property 003 Phone No. Case No. 3 American LegalNet, Inc. www.FormsWorkFlow.com 13. Monthly Income: SourceAmount Payee 14. Monthly Expenses: ItemAmount 15. List major expenditures, dates, amounts and reasons: 16. List assets (checking, savings, etc.), provide balance and date: EVALUATION AND PLAN 17. Have there been any significant events (abuse, death of a loved one, etc.) that occurred duringreport period? [ ] Yes [ ] No. If yes, describe: 4 American LegalNet, Inc. www.FormsWorkFlow.com 18.Opinion of guardian and person regarding quality of care and services provided (consult with wardto the maximum extent possible). Indicate G for guardian and P for person response.Satisfactory Unsatisfactory Living Arrangements Medical Mental Health Social/Rec. Activities Educational/Training Financial Management Explain unsatisfactory evaluations, need for additional services not currently being provided, and your plan to resolve situation: 19.Do you feel person is capable of making any decisions on his/her own?[ ] Yes [ ] No If yes, in what areas:20. Describe persons communication ability (speech, gestures, writing, sign language, use ofadaptive equipment, etc.):21.Guardianship should be: Continued Revoked Changed.Please explain: 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. Guardians Signature Date Co-Guardians Signature Date 5 American LegalNet, Inc. www.FormsWorkFlow.com IN THE FAMILY COURT OF THE SECOND CIRCUIT002 STATE OF HAWAI`I002 In the Matter of the Guardianship of ) 002)002 )002 ) 002, ) 002(Full Legal Name) An Incapacitated Person ) 002)002 )002 . )002 FC-G No. 002NOTICE OF FILING OF ANNUAL REPORT002 NOTICE OF FILING OF ANNUAL REPORT002 STATE OF HAWAI`I 002 TO: 002 Name and Address:002 Name and Address: Name and Address: Name and Address: 6 American LegalNet, Inc. www.FormsWorkFlow.com Notice is hereby given that has submitted the attached Annual Report to the Family Court of the Second 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: Wailuku, Maui, Hawai`i, Signature of Guardian In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if you require a reasonable accommodation for a disability, please contact the ADA Coordinator at the Second Circuit Family Court office by telephone at 244-2700, fax 244-2704, or via email at adarequest@courts.hawaii.gov at least ten (10) working days prior to your hearing or appointment date. Please call the 7 Service Center at 244-2706 if you have any questions regarding forms or procedures American LegalNet, Inc. www.FormsWorkFlow.com