ANNUAL REPORT OF GUARDIAN COURT OF STATE OF NEW YORK COUNTY OF In the Matter of the Annual Report of As Guardian for An Incapacitated Person. Index No. Accounting Period: to General Instructions 1. 2. 3. All guardians must complete Sections I and II All guardians must attach a copy of the order of appointment. If you have been appointed guardian for the personal needs of the incapacitated person, please complete Section III. If you have been appointed guardian for the property management of the incapacitated person, please complete Section IV, the summary and the attached schedules. (a) When listing property on a schedule, please be specific. For instance with bank accounts, list name and address of bank, number of account and balance; with stocks, list number of shares, name of stock, type and value. Gains or losses should be listed in Schedule B or C, whichever applies. If a schedule does not supply enough space, attach additional sheets with reference to the schedule to which the information applies. In any schedule, if there is nothing to list, state "NONE". 4. (b) (c) Revised 7/11/2013 American LegalNet, Inc. www.FormsWorkFlow.com 5. The original annual report should be filed n the office of the Clerk of the Court which appointed you as guardian. Send a copy of the annual report to the incapacitated person by mail, unless the court has ordered otherwise. If the incapacitated person resides in a facility, send a duplicate of the annual report to the chief executive office of the facility. If the incapacitated person resides in a Mental Hygiene facility, send a duplicate of the annual report to the Mental Hygiene Legal Service of the Judicial Department in which the residence is located. If the Mental Hygiene Legal Service was appointed as the court evaluator or counsel for the incapacitated person, send a duplicate of the annual report to the Mental Hygiene Legal Service of the Judicial Department that was the venue of the guardianship proceeding, if so ordered by the Court. Mental Hygiene Legal Services has offices at the following locations: First Department Mental Hygiene Legal Service 41 Madison Ave., 26th Floor New York, New York 10010 Second Department Mental Hygiene Legal Service 170 Old Country Rd. Mineola, New York 11501 Third Department Mental Hygiene Legal Service 286 Washington Avenue Extension Suite 205 Albany, NY 12203 Fourth Department Mental Hygiene Legal Services M. Dolores Denman Courthouse 50 East Avenue - Suite 402 Rochester, New York 14604 6. Revised 7/11/2013 American LegalNet, Inc. www.FormsWorkFlow.com Also send a copy of the annual report to the examiner for your County. The name and address of the examiner for your county may be obtained from County Court or the Appellate Division of State Supreme Court, Third Department. SECTION I INFORMATION PERTAINING TO THE GUARDIAN (all guardians must complete this section). 1. REPORT: Date of initial report: Date of last annual report: Date of this report: Period covered by this report: through (INSTRUCTIONS: except for the first and last year of guardianship, the accounting covers the period from January until the end of December of the year preceding the report, or any other period upon order of the court). 2. GUARDIAN: Name: Address (include mailing address, if different): City Telephone no.: ST ZIP 3. APPOINTMENT: Date of order: Name of Judge/Justice: Revised 7/11/2013 American LegalNet, Inc. www.FormsWorkFlow.com 4. BOND: Bonding company name: Bonding company address: City ST ZIP Value of bond (If the bonding requirement was waived, so state): 5. VISITS: (guardians are required to visit the incapacitated person at least four [4] times a year or more frequently as specified by court order). Have you visited the incapacitated person? Yes No If yes, please provide the date and place of such visits: Date Place If no, please explain: 6. EARNINGS: Have you used or employed the services of the incapacitated person? Yes No Have any moneys been earned by or received on behalf of the incapacitated person based upon such services? Yes No If yes, please set forth date, source and amount of moneys earned or derived from such services: Date Source Amount Revised 7/11/2013 American LegalNet, Inc. www.FormsWorkFlow.com 7. WILL: To your knowledge, has the incapacitated person executed a will? Yes No If yes, please provide location of the will: 8. POWER OF ATTORNEY: To your knowledge, has the incapacitated person executed a Power of Attorney? Yes No If yes, please provide the name and address of the person with the Power of Attorney: City ST ZIP 9. ADDITIONAL INFORMATION: Please provide any additional information which is required by your order of appointment as guardian (In addition to information provided in Sections I, II, III, and IV of this report). Revised 7/11/2013 American LegalNet, Inc. www.FormsWorkFlow.com 10. TYPE OF GUARDIANSHIP: Have you been granted powers over the personal needs of the incapacitated person? Yes No If yes, please complete Sections II and III Have you been granted powers regarding property management of the incapacitated person? Yes No If yes, please complete Sections II and IV 11. CHANGE IN POWERS: Is there any reason for any alteration of your powers as guardian? Yes No If yes, please specify change requested: If you want to change your authorized powers, you must make an application within TEN (10) days of filing this annual report and provide notice to the persons specified in your order of appointment as entitled to such notice. If you fail to comply with this provision, any person entitled to commence a proceeding under this article may petition the court for a change in the powers on notice to you and the persons entitled to such notice as specified in the order of appointment. Revised 7/11/2013 American LegalNet, Inc. www.FormsWorkFlow.com SECTION II INFORMATION PERTAINING TO THE INCAPACITATED PERSON (all guardians must complete this section) 1. INCAPACITATED PERSON:: Name: Address (If residential facility, include name of the Director or person responsible for care): City Telephone no.: ST ZIP Has there been any substantial change in the incapacitated person's mental or physical condition? Yes If yes, please explain: No Has there been any substantial change in the incapacitated person's medication? Yes If yes, please explain: No Revised 7/11/2013 American LegalNet, Inc. www.FormsWorkFlow.com 2. EXAMINATION: Please state the date and place the incapacitated person was last exa