STATE OF ILLINOIS IN THE CIRCUIT COURT OF THE FOURTH JUDICIAL CIRCUIT CLINTON COUNTY, ILLINOIS In Re the Guardianship of: ) ) ) Case No: ) Alleged Disabled Person ) REPORT ON PETITION FOR THE APPOINTMENT OF A GUARDIAN The undersigned, on oath state: 1.The nature and type of disability of the Respondent is 2.and social skills are: These evaluations are based upon examination of Respondent on 3.In our opinion plenary guardianship, both of the person and of the estate of Respondent, isneeded because: 4.We recommend, as the most appropriate treatment or habilitation plan and living arrangementfor Respondent: 5.Signature(s) of person(s) performing evaluations (one of whom must be a licensed physician): Physician Psychologist Social Worker Educator American LegalNet, Inc. www.FormsWorkFlow.com STATE OF ILLINOIS ) ) COUNTY OF CLINTON ) Subscribed and sworn to before me on: Date: Notary Public Prepared by: Address: Telephone: Email: Notes: I.R.S. 110 275 Sec. 11a-or autism; or to (b) any other condition which results in impairment similar to that caused by mental retardation and which requires services similar to those required by mentally retarded persons. Such disability must originate before the age of 18 years, be expected to continue indefinitely, and constitute a substantial handicap. Sec. 11a- years or older who (a) because of mental deterioration or physical incapacity is not FULLY able to manage his person or estate, or (b) is mentally ill or developmentally disabled and who because of his mental illness or developmental disability is not fully able to manage his person or estate, or (c) because of gambling, idleness, debauchery or excessive use of intoxicants or drugs, so spends or waste his estate as to expose himself or his family to want or suffering. Sec. 11a-9 (a) The petition for appointment of a guardian should be accompanied by a report which contains (1) a description of condition, adaptive behavior and social skills; (3) an opinion as to whether guardianship is needed, the type and scope of the guardianship needed, and the reasons therefore; (4) a recommendation as to the most appropriate treatment or habilitation plan and living arrangement for the respondent; and the reasons therefore; (5) the signatures of ALL PERSONS who performed the evaluations upon which the report is based, one of whom shall be a licensed physician. American LegalNet, Inc. www.FormsWorkFlow.com