In the matter of First, middle, and last name , a legally incapacitated individual STATE OF MICHIGANPROBATE COURTCOUNTY OF ANNUAL REPORT OF GUARDIAN ONCONDITION OFLEGALLY INCAPACITATED INDIVIDUAL þ FINAL REPORT FILE NO. 1. þ I, en-USName (type or print)en-US , am the guardian of the adult named above and my annual þ report for the period of en-USDateen-US to en-USDateen-US is as follows. 2. þ Present age of the adult: en-US þ Date of birth: en-US 3. þ en-USLiving Arrangement þ a. þ The current address and telephone number of the adult are: þ þ b. þ The name of the facility where the adult resides, if any: en-US Check here if this is a new addressen-US þ c. þ The adult's residence is: þ own home/apartment þ guardian's home/apartment þ en-US other: en-US(boarding home, assisted living, etc.) þ nursing home þ en-US hospital or medical facility þ foster home þ en-US relative's home: en-USRelationship þ d. þ The adult has been in the present residence since en-USDateen-US . If moved within the past year, state þ the changes and the reasons for change. þ þ en-US þ e. þ I rate the adult's living arrangement as þ excellent. þ average. þ below average. þ en-USExplain þ en-US þ en-US þ en-US en-US þ f. þ I believe the adult is þ content with the living situation. þ en-US unhappy with the living situation. þ þ g. þ I recommend a more suitable living arrangement for the adult as follows: en-US þ en-US þ en-US þ en-US American LegalNet, Inc. www.FormsWorkFlow.com File No. 4. þ en-USPhysical Health þ a. þ The adult's current physical condition is þ excellent. þ good. þ fair. þ en-US poor. þ b. þ During the past year the adult's physical condition has þ þ remained about the same. þ þ improved. þ en-USExplain en-US þ þ worsened. þ en-USExplain en-US þ c. þ During the past year the adult received the following medical treatment (include check-ups and dental work): en-US Dateen-US Ailmenten-US Type of Treatmenten-US Doctor222s Name 5. þ en-USDo-Not-Resuscitate Order þ þ a. þ I did not execute, reaffirm, or revoke a do-not-resuscitate order. þ þ b. þ I þ executed þ reaffirmed þ revoked þ a do-not-resuscitate order for the adult under MCL 700.5314(d). þ In doing so, I þ did þ did not þ consult with the adult and his/her attending physician. þ 6. þ en-USPhysician Orders for Scope of Treatment (POST) Form þ þ a. þ I did not execute, reaffirm, or revoke a POST form. þ þ b. þ I þ executed þ reaffirmed þ revoked þ a POST form for the adult under MCL 700.5314(f). þ In doing so, I þ did þ did not þ consult with the adult and his/her attending physician. þ 7. þ en-USMental Health þ a. þ The adult's current mental condition is þ excellent. þ good. þ fair. þ en-US poor. þ b. þ During the past year, the adult's mental condition has þ þ remained about the same. þ þ improved. þ en-USExplain en-US þ þ worsened. þ en-USExplain en-US þ c. þ During the past year, treatment or evaluation by a psychiatrist, psychologist, or social worker þ was þ en-US was not þ provided. 8. þ en-USSocial Activities/Services þ a. þ The adult's current social condition is þ excellent. þ good. þ fair. þ en-US poor. þ b. þ During the past year, the adult's social condition has þ þ remained about the same. þ þ improved. þ en-USExplain en-US þ þ worsened. þ en-USExplain en-US en-US(SEE THIRD PAGE) American LegalNet, Inc. www.FormsWorkFlow.com File No. en-US8. en-US(continued) þ c. þ During the past year, the adult has participated in the following activities: þ þ recreational en-US þ þ educational en-US þ þ social en-US þ þ occupational en-US þ þ No activities were available. þ þ The adult refused to participate in any activities. þ þ The adult was unable to participate in any activities. 9. þ en-USList of Visits þ a. þ During the past year, I visited the adult as follows: en-USList dates þ þ en-US þ en-US þ b. þ The average amount of time I spent on each visit was en-US en-US . þ c. þ The last time I visited with the adult was on en-USDateen-US . 10. þ en-USActivities þ During the past year, I performed the following activities on behalf of the adult: en-US þ en-US þ en-US 11. þ en-USConsultation þ During the past year, I consulted with the adult before making the following decisions: en-US þ en-US þ en-US 12. þ I believe the adult has the following unmet needs: en-US þ en-US þ en-US þ 13. þ The guardianship þ should þ should not þ be continued because: en-US þ þ en-USNote: en-USIf you no longer wish to serve as guardian, you must file a petition to remove yourself. þ þ 14. þ There þ þ is þ þ is not þ more cash or property than what was previously reported to the court. þ þ If there is, specify the additional amount: þ $ en-US en-US . þ 15. As guardian, I have been ordered by the court to file an annual account, which is attached. en-USDate þ en-USDate þ en-USSignature of guardian þ en-USSignature of co-guardian (if applicable) en-USAddress þ en-USAddress þ þ en-USCity, state, zip Telephone no. þ en-USCity, state, zip Telephone no. Check here if this is a new address þ Check here if this is a new address þ American LegalNet, Inc. www.FormsWorkFlow.com