If additional space is needed please attach a separate page to this form. OSCA (04-19) PR535 1 of 4 475.082, 475.270 RSMo IN THE JUDICIAL CIRCUIT, COUNTY, MISSOURI Judge or Division PROBATE Case Number: In the Estate of , Incapacitated/Disabled Person Guardian and Conservator Annual Status Report and Statement of Affairs 226 Incapacitated/Disabled Person I/We, guardian/co-guardians and conservator/co-conservators of the above named ward submit the following information as required pursuant to the provisions of sections 475.082 and 475.270, RSMo. 1. State the present address of the ward: 2. State your present address: Please check here if your address has changed since filing your last report. 3. If ward does not reside with you, during the last year, how many times have you seen the ward? 4. State the nature and description of your contact with the ward: 5. What was the date you last saw the ward? 6. State the nature and description of your visits with the ward: 7. State any activities the ward has participated in during the past 12 months: 8. To what extent has the ward participated in decision-making? 9. Is the ward currently institutionalized? Yes No Place of institutionalization: Person in charge of institution/home: 10. If institutionalized: As guardian/co-guardians have you received a copy of the treatment or habilitation plan? Yes No If yes, what is the date of such plan: 11. Do you agree with the provisions? Yes No If not, explain what you disagree with: American LegalNet, Inc. www.FormsWorkFlow.com If additional space is needed please attach a separate page to this form. OSCA (04-19) PR535 2 of 4 475.082, 475.270 RSMo 12. When was the ward last seen by a physician or other professional? 13. What was the purpose of the visit? 14. State the current mental and physical condition of the ward: . 15. State any major changes in the condition of the ward: 16. If so, explain, state you observations: 17. In your opinion, should this guardianship/conservatorship be continued? Yes No If no, why not? 18. If you have been appointed limited guardian or conservator, should your powers be increased? Yes No If so, in what respects and why? 19. If you have been appointed full or limited guardian or conservator should your powers be decreased? Yes No If so, in what respects and why? 20. Pursuant to section 475.082.9 RSMo, provide a summarized plan of care for the ward. An individual support plan or treatment plan for the ward for the coming year may be submitted in lieu of this requirement. 21. During the past 12 months did you receive money for the ward from: Social Security Yes Amount annually? No SSI Yes Amount annually? No American LegalNet, Inc. www.FormsWorkFlow.com If additional space is needed please attach a separate page to this form. OSCA (04-19) PR535 3 of 4 475.082, 475.270 RSMo Vet. Admin. (VA) Yes Amount annually? No Other Yes Amount annually? No 22. If other, state the source: . 23. Other than the payments listed above, have you or anyone else received any lump sum payments or other property from any source listed above or from any other source? Yes No If so, state the date received, source, amount (or value) and the present location thereof: 24. Was any money paid to anyone else for the ward222s benefit? Yes No If so, state the source of the money and the name and address of the person receiving it: 25. State the amount of the ward222s money you have spent for the ward during the past 12 months and the purposes of the expenditures: 26. State the total amount of money you presently have on hand for the ward: $ State the name and address of the depository where you keep an account for the ward222s money: 27. Does the ward have life insurance for burial expenses or a burial plan? Yes No If so, state the name of the company and the amount of the benefit: 28. State the services being provided to the protected person: 29. Any other information requested by the court or useful to the court in your opinion? American LegalNet, Inc. www.FormsWorkFlow.com If additional space is needed please attach a separate page to this form. OSCA (04-19) PR535 4 of 4 475.082, 475.270 RSMo 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 for making a false affidavit or declaration. Return to: Signed this day of , 20 Signature of Guardian/Co-Guardians and Conservator/Co-Conservators Printed Name of Guardian/Co-Guardians and Conservator/Co-Conservators Street Address City State Zip Code Telephone Number Email Address Signature of Guardian/Co-Guardians and Conservator/Co-Conservators Printed Name of Guardian/Co-Guardians and Conservator/Co-Conservators Street Address City State Zip Code Telephone Number Email Address FOR COURT USE ONLY Reviewed: Date Judge American LegalNet, Inc. www.FormsWorkFlow.com