State of Minnesota County of ______________________ District Court Probate Division Judicial District: __________________ Court File No. _____________________ Case Type:______________________ In Re: Guardianship Conservatorship of ________________________________ TO THE HONORABLE JUDGE OF THE DISTRICT COURT: Report of: Guardian Conservator Guardian's Report Conservator's Report Within 30 days from the occurrence of any event listed in Minn. Stat. § 524.5-316(b) and § 524.5-420(d), the guardian / conservator must submit to the Court a written Report which details a change in events of the guardian / conservator or any employee of the guardian / conservator who is responsible for exercising powers and duties under the guardianship / conservatorship. A copy of the Report must be provided to the ward / protected person and to interested persons of record with the court. The court may decline to appoint or may remove a person as guardian or conservator for failure to report. Name of Guardian / Conservator: Address: Telephone number: If the reportable event involves your employee, provide the employee's information below: Name of Employee: Address: Telephone number: (name) 1. has been removed for cause from serving as a guardian or conservator and the court location and court file number are: GAC109 State ENG Rev 7/15 www.mncourts.gov/forms Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 2. has the following professional license from an agency listed under Minn. Stat. § 524.5-118, subd. 2a, which has been denied, conditioned, suspended, revoked, or cancelled. The licensing agency, licensing number and the basis for the denial, condition, suspension, revocation, or cancellation of the license is as follow: 3. has been found civilly liable in an action involving fraud, misrepresentation, material omission, misappropriate, theft, or conversion. List court location and court case number: 4. has filed or has received protection under the bankruptcy laws. List court location and court case number: 5. has outstanding civil monetary judgments. List court location, court case number, and outstanding amount owed: 6. has been convicted of a crime. List court case number and convicted offense: 7. has an order for protection or harassment restraining order issued against him / her. Dated:_____________, 20____ Signature Print Name: Address: City/State/Zip: E-mail address: GAC109 State ENG Rev 7/15 www.mncourts.gov/forms Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com