Report of Guardian Cover Page Superior Court of New Jersey Chancery Division - Probate Part County of Docket No. In the Matter of the Report of , Guardian(s) for , an Incapacitated Person. Civil Action Guardian's Report for the Period to This report must be filed by every Guardian within fourteen (14) days of the anniversary date of your appointment, which is , unless the Judge otherwise specifies. File the original with the Surrogate. 1. Guardian's Current Information* Street address: City: State: Zip: Include mailing address, if different Mailing address: City: State: Zip: Daytime Telephone Number: Evening Telephone Number: Select one: Guardian of Person Guardian of Estate Guardian of Both Person and Estate Guardian's relationship to the Incapacitated Person? ____________________________________________ * If needed: attach a separate page with the current information for any co-guardian(s). 2. Incapacitated Person's Current Information: does he/she reside with the guardian? Yes If No, complete the incapacitated person's residency information below. If Yes, continue to #3. No A. Incapacitated Person's address: If the incapacitated person lives in a residential facility, include the name of the Director or person responsible for the incapacitated person's care. Address: City: State: Zip: Telephone Number: Contact Name: Telephone Number: B. State the average number of visits you or your designee made to the Incapacitated Person during the period: . 3. Identify all Guardianship responsibilities (check all that apply): Manage financial affairs Provide necessities Provide transportation Housekeeping List all other responsibilities assumed: Feed Bathe Take on outings Provide continuous care 4. State if you believe the guardianship should continue? State reason: Yes No 5. Are any modifications or adjustments needed in the guardianship? If Yes, describe: Yes No Revised: 02/2017, CN: 11797 (Guardianship - Report of the Guardian Cover Page) American LegalNet, Inc. www.FormsWorkFlow.com