Nebraska State Court Form REQUIRED ANNUAL REPORT OF GUARDIAN ON CONDITION OF WARD/INCAPACITATED PERSON CC 16:2.14 Page 1 of 4 Annual RepoIN THE COUNTY COURT OF COUNTY, NEBRASKA IN THE MATTER OF THE GUARDIANSHIP Ward/Incapacitated Person Case ANNUAL REPORT OF GUARDIAN ON CONDITION OF WARD/INCAPACITATED PERSON I, the undersigned, am the guardian and conservator of the above named ward/incapacitated person and my annual report to the court is as follows: 1.Present age of the ward/incapacitated person:2.Current address of the ward/incapacitated person: 3. own home nursing home hospital or medical facility foster or boarding home other: (Relationship) 4.The ward/incapacitated person has lived in his or her current residence since. If the ward/incapacitated person has moved within past year, state reasons for change:5.During the past year, how many times and on what dates did you see the ward/incapacitatedperson? 6. remained about the same. improved. Describe: deteriorated. Describe: Page 2 of 4 Annual Report of Guardian on Condition of the Ward/Incapacitated Person CC 16:2.14 Rev 7. remained about the same. improved. Describe: deteriorated. Describe: 8.During the past year, the ward/incapacitated person has been treated or evaluated by the following: Physician. Name: Psychiatrist. Name: Social or other case worker. Name: Dentist. Name: Other. Name: 9.The ward/incapacitated person is e: (if different than physician in #8 above) 10.Social conditions: During the past year, the ward/incapacitated person has participated in thefollowing activities: Describe. Recreational: Educational: Social: Occupational: None available. Refuses or unable to participate. 11. excellent. average. below average. If below average, explain: 12.As guardian, I believe the ward/incapacitated person is: content with living situation. unhappy with living situation. Why? 13.As guardian, I believe the ward/incapacitated person has the following needs that have not beenmet: 14.The guardianship should be continued for the following reasons: The ward/incapacitated person is still a minor. inuation of guardianship. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 Annual Report of Guardian on Condition of the Ward/Incapacitated Person CC 16:2.14 Rev 15.Please mark one of the following (A, B, or C) and complete the additional questions, if any, for the section you marked: A) I do possessions or income (including social security or other benefits) AND one of the following applies: 1)My accounting, certificate of proof of possession, and bank statements are filed with the court. 2)The accounting has been waived by the court. 3)A budget has been approved by the court and the Annual Budget Report is filed with the court. B)I do not assets, possessions or income (including social security or other benefits). The person whoincome (including social security or other benefits) is: AND I have talked to the person in charge of the money, assets, possessions or income (including social security or otherbenefits) ANDI am satisfied that the funds are being handled properly.I am not satisfied that the funds are being handled properlybecause 2)I have not other benefits) because C)The ward/incapacitated person receives no money, assets, possessions or income (including social security or other benefits). . . American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4 Annual Report of Guardian on Condition of the Ward/Incapacitated Person CC 16:2.14 Rev I swear or affirm, under the penalties of perjury, that I have examined the Annual Report of Guardian on Condition of Ward/Incapacitated Person, and to the best of my knowledge and belief, it is true, correct and complete. Date Signature(s) of Guardian(s) Print or Type Name of Guardian(s) Bar Number and Firm Name (attorneys only) Street Address/P.O. Box of Guardian(s) City/State/ZIP Code of Guardian(s) Phone of Guardian(s) E-mail Address of Guardian(s) American LegalNet, Inc. www.FormsWorkFlow.com