GAC 11 - U State ENG Rev 11/18 www.mncourts.gov/forms Page 1 of 5 State of Minnesota District Court Probate Division County Judicial District: Court File No.: Case Type: 14, Guardianship In Re: the Guardianship of Personal Well - Being Report (Annual Report of Guardian) Minn. Stat. 247 524.5 - 316 Ward As required by Minnesota law, I make this annual Personal Well-Being Report for the reporting period from to . My name, and the address and phone number where I can be contacted: Name: Street Address: City, State and Zip Code: Phone: Type: Email: The Ward 1. Current Address arrangement: Street Address: City, State and Zip Code: Living Arrangement: 2. Previous Addresses. Has the Ward lived at any other address during this reporting period? If No, skip to #3. If Yes: Street Address: City, State and Zip Code: Living Arrangement: Date Range Ward Lived Here: If there is more than one previous address, add another sheet. The Guardian (Me) American LegalNet, Inc. www.FormsWorkFlow.com GAC 11 - U State ENG Rev 11/18 www.mncourts.gov/forms Page 2 of 5 Current Conditions current mental, physical, and social conditions by choosing a number on a scale of 1 to 5 (1 = very poor, and 5= excellent). Then give a brief explanation of why you rated the way you did. 3. mental condition as: 1 2 3 4 5 Very poor Excellent The reason I gave this rating: 4. physical condition as: 1 2 3 4 5 Very poor Excellent The reason I gave this rating: 5. social condition as: 1 2 3 4 5 Very poor Excellent The reason I gave this rating: 6. Contact with the Ward. a. In the last year, I have had contact with the Ward: b. I usually contact the Ward: The Guardianship American LegalNet, Inc. www.FormsWorkFlow.com GAC 11 - U State ENG Rev 11/18 www.mncourts.gov/forms Page 3 of 5 Services For questions #7 through #10, tell whether the Ward received any medical, educational, vocational, or other services in the last year. Then, you should: Describe the services; Tell whether you believe the services were adequate; and If services were not adequate, explain why not. 7. Did the Ward receive any medical services in the past year? If Yes: Describe: Were the medical services adequate? 8. Did the Ward receive any educational services in the past year? If Yes: Describe: Were the educational services adequate? 9. Did the Ward receive any vocational services in the past year? If Yes: Describe: Were the educational services adequate? 10. Did the Ward receive any other services in the past year? American LegalNet, Inc. www.FormsWorkFlow.com GAC 11 - U State ENG Rev 11/18 www.mncourts.gov/forms Page 4 of 5 If Yes: Describe: Were the other services adequate? 11. Restrictions. and visit with anyone? If Yes: What happened to cause these restrictions? 12. Reimbursement for Services. Have you received any money as reimbursement for services the Ward received in the past year? If Yes: How much did you receive? $ Was any of this money reimbursed by county contract? 13. Continuation or Changes to the Guardianship. Any information you include here is so that the court knows your opinion about the guardianship. This is not a formal request to change or end the guardianship (there are other forms available at http://mncourts.gov/GetForms.aspx?c=21 for making these requests). a. Do you believe the Ward should still be under guardianship? Explain: b. Do you think the guardianship should be changed? American LegalNet, Inc. www.FormsWorkFlow.com GAC 11 - U State ENG Rev 11/18 www.mncourts.gov/forms Page 5 of 5 Explain: 14. Are you a professional guardian? Under Minnesota law, a professional guardian means a person acting as guardian for three or more people who are not related to the guardian by blood, adoption, or marriage. Everything I have stated in this report is true and correct. Dated Signature of Guardian Name: Address: City/State/Zip: Telephone: Email: Each year, this report must be given to the Ward and to interested persons of record with the court within 30 days after the anniversary of the appointment of the guardian. If the Personal Well - Being Report is not filed within 60 days of the due date, the court shall issue an Order to Show Cause. An interested person may notify the court in writing that he or she does not want to receive copies of annual reports as required by law. American LegalNet, Inc. www.FormsWorkFlow.com