IN THE CIRCUIT COURT OF JACKSON COUNTY, MISSOURI - PROBATE DIVISION AT IN THE ESTATE OF ESTATE NUMBER , Ward - Protectee. ANNUAL STATEMENT OF AFFAIRS OF GUARDIAN-CONSERVATOR (Sec. 475.082, RSMO) (No Further Process) 1. State present residence address of ward: 2. State the type and the name, if any, of the home or facility where the ward lives and the name of the person in charge of the home. 3. State your present residence address: 4. During the last year, how many times have you seen the ward? date when you last saw the ward? State the nature of your visits: 5. Is there a plan for the ward's care, training or treatment? If not, explain what you disagree with: provisions? What was the If so, do you agree with its 6. When was the ward last seen by a physician? What was the purpose of the 7. Have you observed any major changes in the ward's physical or mental condition during the last If so, state your observations: 8. In your opinion, should this guardianship/conservatorship be continued? visit? year? If not, why not? 9. If you have been appointed limited guardian or conservator, should your powers be decreased? If so, in what respects and why? (Attach additional sheets if necessary.) Form 10199 7/29/96 2001 © American LegalNet, Inc. 10. decreased? If you have been appointed full or limited guardian or conservator, should your powers be If so, in what respects and why? 11. What is your opinion of the present care being provided to the ward? 12. During the past 12 months did You receive money for the ward from: Social Security Yes If yes, how much? $ No SSI Yes If yes, how much? $ No Vet. Admin. (VA) Yes If yes, how much? $ No Other Yes If yes, how much? $ No If other, state source: 13. Was any money paid to anyone else for the ward's benefit? the name and address of the person receiving it: If so, state the source of the money and 14. Other than the payments listed in Question 12, have you or anyone else received any lump sum payments or other property from any source listed above or from any other source? If so, state the date received, source, amount (or value) and the present location thereof: 15. State the amount of the ward's money you have spent for the ward during the past 12 months and the purposes of the expenditures: 16. State the total amount of money you presently have on hand for the ward: $ address of the depository here you keep an account for the ward's money: , State the name and 17. Does the ward have life insurance for burial expenses or a burial plan? If so, state the name of the company and the amount of the benefit: The undersigned swears that the answers set forth above are true and correct to the best knowledge and belief of the undersigned, subject to the penalties of making a false affidavit or declaration. Dated: SIGNED: TELEPHONE: Form 10199 2 7/29/96 2001 © American LegalNet, Inc.