1 Form 4-996. Guardian222s report. [For use with Rule 1-140 NMRA] STATE OF NEW MEXICO COUNTY OF JUDICIAL DISTRICT In the matter of , No. a Protected Person. GUARDIAN222S REPORT TYPE OF REPORT: 001 90-day 001 Annual 001 Final Date of your appointment as guardian: Instructions. You must use this form, Form 4-996 NMRA, when you file a Guardian222s Report. The purpose of this Guardian222s Report is to give the court information about an adult for whom a guardian has been appointed. 1.You must complete and file this Guardian222s Report, as follows:a.Within ninety (90) days of your appointment as guardian by the court;b.Every year within thirty (30) days of the anniversary date of yourappointment as guardian;c.Within thirty (30) days of your resignation, removal, or termination asguardian; andd.As otherwise ordered by the court.2.Please type or print clearly using ink.3.Complete all sections of this report that apply, and answer all questionsthoroughly.4.Attach additional pages if necessary.5.After completing this report, you must sign it under penalty of perjury.6.Copies of this report must be given to the Protected Person, the ProtectedPerson222s conservator if one has been appointed, and any other persons specifiedby the court.7.Keep a copy of this report for your records.8.If you give financial information in Section (IV)(D) of this report, you must keepa copy of ALL of the Protected Person222s financial records for seven (7) yearsand make them available to the court upon request. American LegalNet, Inc. www.FormsWorkFlow.com 2 001 The Protected Person has died (attach a copy of the death certificate if available). Date and place of death: Name of personal representative, if appointed: Address: 001 The court has appointed a new guardian. Name of new guardian: Address and phone number of new guardian: 001 The court has issued an order ending the guardianship. 001 Other (please explain): SECTION I 226 Information about the Protected Person. A.Protected Person222s name: B.Protected Person222s age: C.Protected Person222s physical address: Mailing address (if different): D.Protected Person222s telephone number(s) and other contact information:Home: Cell: Work: Fax: If this is a Final Report, please check the box below that explains why you are filing a Final Report, and fill in the requested information. If this is not a Final Report, skip to Section I. American LegalNet, Inc. www.FormsWorkFlow.com 3 Email: E. Has the Protected Person222s residence changed in the last 12 months? 001 Yes 001 No If yes, please explain why: F. Will the Protected Person222s residence change in the next 12 months? 001 Yes 001 No 001 Unknown If yes, please explain why: G. Does the Protected Person live in a facility? 001 Yes If yes, complete Part A, below (do not complete Part B). 001 No If no, complete Part B, below (do not complete Part A). PART A Complete Part A only if the Protected Person lives in a facility. H. What type of facility does the Protected Person live in? 001 Assisted Living Facility 001 Group Home 001 Licensed Nursing Facility 001 Other (please explain) I. Name of Facility: American LegalNet, Inc. www.FormsWorkFlow.com 4 Facility contact person222s name: Facility222s physical address: Facility222s contact information: Telephone: Email: J. How is the facility paid for? K. Do you have any concerns about the quality of care that the Protected Person is receiving in the following areas? Cleanliness 001 Yes 001 No Nutrition/Meals 001 Yes 001 No Personal Care 001 Yes 001 No Privacy 001 Yes 001 No Individualized Care Plans 001 Yes 001 No Safety 001 Yes 001 No Other: 001 Yes 001 No If you marked yes to any of the above, please explain: L. Has the Protected Person been restricted from communicating, visiting, or interacting with others? 001 Yes 001 No If yes, describe the restrictions: American LegalNet, Inc. www.FormsWorkFlow.com 5 What are the reasons for the restrictions? Who imposed the restrictions? When were the restrictions imposed? Are the restrictions still in place? 001 Yes 001 No M. Have others been restricted from communicating, visiting, or interacting with the Protected Person? 001 Yes 001 No If yes, describe the restrictions: What are the reasons for the restrictions? Who imposed the restrictions? When were the restrictions imposed? Are the restrictions still in place? 001 Yes 001 No N. Why was this facility chosen for the Protected Person? O. How does the Protected Person feel about the placement? American LegalNet, Inc. www.FormsWorkFlow.com 6 P. Do you believe the Protected Person could live and function more independently in a different type of setting? 001 Yes 001 No Please explain your answer: Q. Have you tried to change the Protected Person222s residence in the past year? 001 Yes 001 No If yes, what was the outcome? How does the Protected Person feel about the change of residence? END OF PART A 226 If you filled out Part A, skip to Section II. PART B Complete Part B only if the Protected Person does not live in a facility. H. Describe the Protected Person222s living arrangement: I. Who takes care of the Protected Person? Caregiver222s physical address: Caregiver222s contact information: Telephone: Email: American LegalNet, Inc. www.FormsWorkFlow.com 7 J. Do you have any concerns about the quality of care that the Protected Person is receiving in the following areas? Cleanliness 001 Yes 001 No Nutrition/Meals 001 Yes 001 No Personal Care 001 Yes 001 No Privacy 001 Yes 001 No Safety 001 Yes 001 No Other: 001 Yes 001 No If you marked yes to any of the above, please explain: K. List all people living with the Protected Person and their relationship to the Protected Person: L. Has anyone moved into or out of the Protected Person222s residence during the last 12 months? 001 Yes 001 No If yes, please explain: M. List any person who lives with the Protected Person and is paid to provide services for the Protected Person. (attach additional pages if necessary) Name: Relationship to Protected Person: Types of Services: American LegalNet, Inc. www.FormsWorkFlow.com 8 Payment: Source of Payment: N. Do you have concerns about anyone who lives with the Protected Person? 001 Yes 001 No If yes, please explain: O. Why was this living arrangement chosen for the Protected Person? P. How does the Protected Person feel about the living arrangement? Q. Do you believe the Protected Person could live and function more independently in a different type of setting? 001 Yes 001 No Please explain your answer: R. Have you tried to change the Protected Person222s residence in the past year? 001 Yes 001 No If yes, what was the outcome? American LegalNet, Inc. www.FormsWorkFlow.com 9 How does the Protected Person feel about the change of residence? S. Has the Protected Person been restricted from communicating, visiting, or interacting with others? 001 Yes 001 No If yes, describe the restrictions: What are the reasons for the restrictions? Who imposed the restrictions? When were the restrictions imposed? Are the restrictions still in place? 001 Yes 001 No T. Have others been restricted from communicating, visiting, or interacting with the Protected Person? 001 Yes 001 No If yes, describe the restrictions: What are the reasons for the restrictions? Who imposed the restrictions? American LegalNet, Inc. www.FormsWorkFlow.com 10 When were the restrictions imposed? Are the restrictions still in place? 001 Yes 001 No END OF PART B 226 Continue to Section II. SECTION II - Protected Person222s Health. A. Please describe the Protected Person222s current physical health: 001 Poor 001 Fair 001 Good 001 Excellent Please explain: Please describe any changes to the Protected Person222s physical health in the last 12 months: Please describe any medical treatment the Protected Person received in the last 12 months: B. Please describe the Protected Person222s current mental health: 001 Poor 001 Fair 001 Good 001 Excellent Please explain: Please describe any changes to the Protected Person222s mental health in the last 12 months: American LegalNet, Inc. www.FormsWorkFlow.com 11 Please describe any mental health treatment the Protected Person received in the last 12 months: C. Is the