ANNUAL REPORT AND INFORMAL ACCOUNTING OF GUARDIAN Superior Court of New Jersey Chancery Division, Probate Part In the Matter of the Annual Report of __________________ County _____________________________, Docket No. _______________ As Guardian for__________________, An Incapacitated Person This report must be filed by every guardian once per year unless the Judge otherwise specifies, on the anniversary date of your appointment, which is___________. The original must be filed with the Surrogate along with a filing fee of $ 5.00 per page made payable to MERCER COUNTY SURROGATE and a copy must also be sent to court-appointed counsel for the ward at the following address: Surrogate: Mercer County Surrogate PO Box 8068 Trenton, New Jersey 08650-0068 1. 2. Court Appointed Counsel: _____________________________ _____________________________ _____________________________ Date of Report______________________ Guardian: Please Check: Name:____________________________ ___guardian of person only Address: (include mailing address, ___guardian of property only if different) ___guardian of both _______________________________ _______________________________ _______________________________ Telephone No. (Day)________________________ (Evening)_____________________ 3. Incapacitated Person: Name:_______________________________ Address: (If the person lives in a residential facility, include name of the Director or person responsible for care)____________________ _____________________________________ _____________________________________ Telephone No. _________________________ American LegalNet, Inc. www.USCourtForms.com 4. Bond: Bonding company name:_______________________________ Bonding company address:_____________________________ _____________________________ Value of Bond (If the bonding requirement is waived, so state): 5. Guardian's relationship to ward: 1___ spouse 2 ___parent of ward 3___child of ward 5 ___ friend 4 ___other relative 8___other 6 __private attorney 7__public guardian or agency 6. Does the ward live with you? ____Yes ____ No. If not, how many times do you or your designee visit the ward on an average each month?_______. On average, how long is the visit (in minutes)?______________ What does the guardian do for the ward? Check all that apply: _______Manage financial affairs _______Housekeeping _______Provide transportation _______Feed List any others: ________Provide necessities ________Take on outings ________Bathe _______Provide continuous care 7. IF YOU ARE A GUARDIAN OF THE PERSON, PLEASE COMPLETE THE FOLLOWING QUESTIONS. IF YOU ARE A GUARDIAN OF THE PROPERTY ONLY, PLEASE GO TO QUESTION 19. 8. What is the guardian's view of the ward's overall situation, including any significant changes in physical health, intellectual functioning, emotional health and living situation that have occurred over the past year; -2- American LegalNet, Inc. www.USCourtForms.com 9. Does the guardian feel that the guardianship should continue? __yes __no Why? 10. Has there been any substantial change in the incapacitated person's medication? ___yes ___ no If yes, please explain: Examination: Please state the date and place the incapacitated person was last examined or otherwise seen by a physician and the purpose of such visit: Date Physician Purpose 11. Please attach a statement by a physician, psychologist, nurse clinician or social worker, or other person who has evaluated or examined the incapacitated person within three (3) months prior to the filing of this report, regarding an evaluation of the incapacitated person's condition and current functioning level. 12. Residential setting: Is the current residential setting suitable to the needs of the incapacitated person? ___ yes ___ no If no, please explain: 13. Treatment: What professional medical treatment, if any, has been given to the incapacitated person during the proceeding year? Date Treatment -3- American LegalNet, Inc. www.USCourtForms.com 14. Treatment Plan: Describe the treatment plan for the coming year for the incapacitated person regarding: (a) (b) (c) (d) Medical treatment Dental treatment Mental health treatment Additional related services 15. Social Skills: Please provide information concerning the condition of the incapacitated person's social skills and needs and the social and personal services by the incapacitated person___________________________________________ ___________________________________________________________ Any changes needed in the guardianship?__________________________ Has eligibility for such programs as Social Security, Medicare, Medicaid, SSI or Food Stamps ever been checked? ____yes ___no Does the guardian need assistance, whether from the court or from a community agency? Please specify:______________________________ ___________________________________________________________ ____________________________________________________________ 16. 17. 18. -4- American LegalNet, Inc. www.USCourtForms.com 19. Guardian's current assessment of ward's (check a rating box for each category) Excellent Satisfactory Fair Poor Don't know Physical health Emotional health Intellectual functioning Living situation PROPERTY MANAGEMENT If you have been granted powers regarding the property management of the incapacitated person, please provide the following information, consistent with your order of appointment, pertaining to your fulfillment of your responsibilities to the incapacitated person to provide for property management: 20. Have you identified, traced and collected assets of the incapacitated person since your appointment? ____yes ____no If no, please explain: 21. Have all of the incapacitated person's past and current income tax returns and payments been brought up to date? ____yes ____no If no, please explain: 21. Please complete the following schedules and summary. If you have nothing to list on a schedule, state "NONE". -5- American LegalNet, Inc. www.USCourtForms.com SCHEDULE A Assets on Hand at the Beginning of the Accounting Period Please list all assets of the incapacitated person over which you had sole control as guardian as of the beginning of the accounting period. Do not include in this schedule, trust principal in which the incapacitated person has an interest, property under joint control of any court, or real property not transferred to the guardian. 1. BANK ACCOUNTS AND CASH ­ please list the name and address of institutions, account numbers and balance deposited in banks or other financia