Examiner Name: _________________________ EXAMINER'S REPORT ON ANNUAL REPORT OF GUARDIAN, COMMITTEE OR CONSERVATOR* (Mental Hygiene Law § 81.31) Period of Accounting: ____________________________ Name of Incapacitated Person: ___________________________ Index No. ______________________ Reporting Guardian of Person and Property: ________________________________________________ Reporting Guardian of Person ONLY: _____________________________________________________ Reporting Guardian of Property ONLY: ____________________________________________________ Name of Judge or Justice Appointing Guardian: _____________________________________________ Date of Order/Judgment Appointing Guardian: ______________________________________________ Date of filing of Guardian's Annual Report: _________________________________________________ Date of filing of Guardian's Last Annual Report: _____________________________________________ I - GENERAL 1. Does the annual report provide all of the information concerning the incapacitated person required by Mental Hygiene Law § 81.31 (b) (1) - (5)? Yes No If not, in what respect is the report deficient? 2. Has the guardian discharged the duty to visit the incapacitated person at least four times a year as required by Mental Hygiene Law § 81.20 (5) (a)? Yes If not, please explain. No * As used in this report, the term "guardian" shall also be deemed to refer to committees or conservators appointed prior to April 1, 1993. 1 Rev: 1/16 American LegalNet, Inc. www.FormsWorkFlow.com II - PROPERTY MANAGEMENT Complete this section only if guardian has been granted powers with respect to property management. 3. To the extent that the guardian is charged with property management, does the report contain an accounting of the property of the incapacitated person as required by Mental Hygiene Law § 81.31 (b) (7)? Yes 4. No Provide the following figures from the guardian's accounting: a. b. c. Value of estate as of last report (Schedule A): Assets received (Schedule B): Income received (Schedule C): Subtotal assets and income: d. e. Losses incurred (Schedule D): Disbursements paid (Schedule E): Subtotal losses and disbursements: f. Closing balance of estate (Schedule F): 5. Is the examiner satisfied that the accounting is accurate and complete and have all items of income and disbursement been satisfactorily verified by bank statements, bills, receipts, cancelled checks and the like? Yes No If not, please explain 2 Rev: 1/16 American LegalNet, Inc. www.FormsWorkFlow.com III - PERSONAL NEEDS 6. To the extent that the guardian is charged with providing for personal needs, does the report contain each of the following items required by Mental Hygiene Law § 81.31 (b) (6)? a. statement as to whether current residential setting is best suited to the current needs of the incapacitated person. Yes b. No summary of professional medical treatment given to the incapacitated person in preceding year. Yes No c. plan for medical, dental and mental health treatment, and related services for coming year. Yes No d. information concerning the social condition of the incapacitated person (see Mental Hygiene Law § 81.31 [b] [6] [iv]). Yes No If not, in what respects is the report deficient? 3 Rev: 1/16 American LegalNet, Inc. www.FormsWorkFlow.com IV - TERMINATION OR ALTERATION OF POWERS 7. Does the report contain any facts indicating the need to terminate the guardian's appointment or to alter the guardian's power? Yes If yes, please explain. No 8. If the report indicates any reason for a change in powers authorized by the Court, has the guardian made application within 10 days of filing of the report as required by Mental Hygiene Law § 81.31 (e)? Yes No Not Applicable If application has not been made, please explain briefly. COMPENSATION 9. Examiner's compensation is governed by 22 NYCRR 806.17 (c). Attach request for payment of reasonable and necessary disbursements. In estates of $5,000 and under, submit a standard state voucher. Amount of disbursements, if any, claimed by examiner: ______________________________ Date of this Report (your signature) (your name and address) 4 Rev: 1/16 American LegalNet, Inc. www.FormsWorkFlow.com