ANNUAL REPORT OF GUARDIAN Superior Court of New Jersey Bergen Chancery Division -- ______________County Probate Part In the Matter of the Annual Report of Docket No. _______________ _________________________, Guardian for CIVIL ACTION Guardian’s Annual Report for the Period ___________________ to ________________ _______________________, 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 ____________________. File the original with the Surrogate and a copy with the court-appointed counsel for the ward at the following addresses: Surrogate Address Court Appointed Counsel Address 1. Date of Report: 2. Guardian’s Current Information: Name: Address: 1 Please Check: □ Guardian of Person □ Guardian of Estate □ Guardian of Both Person and Estate Telephone No.: Day: Evening: 1 Include mailing address, if different. 3. Incapacitated Person Current Information 4. Bond Information: Name: Address: 2 Bonding Company’s Name: Address: Telephone No.: Value of bond 3 $ 2 If the incapacitated person lives in a residential facility, include the name of the Director or person responsible for the incapacitated person’s care. Revised 07/11/2008, CN 10508 - English 3 : If the bonding requirement was waived, so state. Page 1 of 7 American LegalNet, Inc. www.FormsWorkflow.com 5. Guardian’s Relationship to Incapacitated Person A. _____ Spouse/ Civil or Domestic Partner B. _____ Parent C. _____ Child D. ____ Other Blood Relative E. ______ Friend F. ____ Private Attorney G. ____ Public Guardian or Public Agency H. ____ Other 6. Does the Incapacitated Person live with you? Yes No If No, State the average number of visits you or your designee make each month? __________ What is the average length of said visits (in minutes)? ________ Identify all Guardianship Responsibilities Check all that apply: □ Manage financial affairs □ Provide necessities □ Provide transportation □ Take on outings □ Housekeeping □ Bathe □ Feed □ Provide continuous care □ List All other Responsibilities Assumed: IF YOU ARE GUARDIAN OF THE PERSON, COMPLETE THE FOLLOWING QUESTIONS IF YOU ARE GUARDIAN OF THE PROPERTY ONLY, GO TO QUESTION 19. 8. Describe the incapacitated person's overall situation, including any significant changes in physical health, intellectual functioning, emotional health and living conditions over the past year. 9. State if you believe the guardianship should continue. State reason: yes no 10. Has there been any substantial change in the incapacitated person’s medication? If yes, please explain: yes no 11. Medical Examination: State the date and medical professional that last examined the incapacitated person and the purpose of such visit: Date: Physician: Purpose: 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 functional level. Revised 07/11/2008, CN 10508 - English Page 2 of 7 American LegalNet, Inc. www.FormsWorkflow.com 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 preceding year? Treatment Date 14. Treatment Plan: Describe the treatment plan for the coming year for the incapacitated person regarding: (a) Medical treatment (b) Dental treatment (c) Mental Health treatment (d) Additional related services 15. Social Skills: Provide information concerning the condition of the incapacitated person's social skills and needs and the social and personal services used by the incapacitated person. 16. Are any modifications or adjustments needed in the guardianship? Please Describe. 17. Has eligibility for such programs as Social Security, Medicare, Medicaid, SSI or Food Stamps been investigated? yes no If no, state reason. 18. Is assistance, whether from the court or from a community agency, required? Please specify the assistance believed to be required. Revised 07/11/2008, CN 10508 - English Page 3 of 7 American LegalNet, Inc. www.FormsWorkflow.com 19. Guardian’s current assessment of Incapacitated Person's: (check a rating box for each category) 1 Excellent 2 Satisfactory 3 Fair 4 Poor 5 Don’t Know Physical Health Emotional Health Intellectual Functioning Living Situation Management of the Incapacitated Person’s Estate If the Court has granted powers regarding the control and management of the incapacitated person's estate, please provide the following information, consistent with your order of appointment, concerning your fulfillment of your responsibilities to the incapacitated person: 20. Have you identified, traced and collected all of the incapacitated person’s assets since your appointment? Yes No If No, please explain: 21. Have all of the incapacitated person's past and current state and federal tax returns been prepared and filed and all tax payments made? Yes No If No, please explain: 22. Complete the following financial schedules. If you have nothing to list on a schedule, state "NONE". If additional space is required, attach a separate sheet of paper. SCHEDULE A - ASSETS ON HAND AT THE BEGINNING OF THE ACCOUNTING PERIOD List all assets of the incapacitated person over which you had control as guardian as of the beginning of the reporting period. Do not include in this schedule, trust principal in which the incapacitated person has an income interest, property under joint control of any court or real property not transferred to the guardian. 1. BANK ACCOUNT AND CASH – Name and Address of Financial Institution Account number Account Balance Cash on hand not in bank accounts. Revised 07/11/2008, CN 10508 - English Page 4 of 7 American LegalNet, Inc. www.FormsWorkflow.com 2. CORPORATE AND GOVERNMENT DEBT INSTRUMENTS AND SECURITIES (e.g., Corporate Stocks and Bonds; Federal, State or Municipal Bonds and notes. Description Market Value 3. PRESENT OR FUTURE INTERESTS (e.g., Interests in Partnerships, Trusts, Litigation Settlement Funds or Pensions) List the estimated values of all present and future interests the incapacitated person has in property that has not been transferred to your control. Market Value Interest 4. OTHER TANGIBLE AND INTANGIBLE PERSONAL PROPERTY (e.g., Furniture, Jewelry, Artwork) List and describe other personal property and indicate estimated value. Market Value Property Description 5. REAL PROPERTY Address/Location Type of Real Property Interest SCHEDULE B - ASSETS RECEIVED DURING ACCOUNTING PERIOD List all principal assets received during the period of this report Property Description Source Date Received Market Value Amount or Value SCHEDULE C - INCOME RECEIVED DURING ACCOUNTING PERIOD List all income received during the period from property interests listed in Schedules A and B. Source Date Received Amount Revised 07/11/2008, CN 10508 - English Page 5 of 7 American LegalNet, Inc. www.FormsWorkflow.com SCHEDULE D - LOSSES INCURRED DURING ACCOUNTING PERIOD List all realized losses incurred on principal assets, whether due to sale, liquidation or asset depreciation. Asset Transaction Type Amount of Loss Date SCHEDULE E - Moneys Paid Out During Accounting Period (List all disbursements, excluding investments, during the period) Payee Purpose of Payment Amount Date of Payment Revised 07/11/2008, CN 10508 - English Page 6 of 7 American LegalNet, Inc. www.FormsWorkflow.com SCHEDULE F - ASSETS ON HAND AT END OF THE ACCOUNTING PERIOD List assets of the type listed in Schedule A on hand at the end of the period and value thereof (see Schedule A for further instructions) 1. BANK ACCOUNTS AND CASH Name and Address of Financial Institution Account number Account Balance Cash on hand (not in bank or financial institution accounts) 2. CORPORATE AND GOVERNMENT DEBT INSTRUMENTS AND SECURITIES Description Market Value 3. PRESENT AND FUTURE INTERESTS Interest Market Value 4. OTHER TANGIBLE AND INTANGIBLE PERSONAL PROPERTY Property Description Market Value 5. REAL PROPERTY Address/Location Type of Real Property Interest Market Value CERTIFICATION ___________________________________(insert your name), certifies that I am the Guardian of the within named incapacitated person and that the attached annual report and schedule(s) (is) (are), to the best of my personal knowledge, complete and true statement of my activities as such Guardian. I am aware that if any of the foregoing statements are willfully false, I am subject to punishment. /s/ ___________________________ Date Revised 07/11/2008, CN 10508 - English Guardian Print Name Page 7 of 7 American LegalNet, Inc. www.FormsWorkflow.com