EXAMINER'S REPORT ON GUARDIAN'S INITIAL REPORT (MHL §§ 81.30, 81.32 [a] [1]) Name and address of Incapacitated Person: ______________________________ ______________________________ City: ______________________________ State: ____________ Zip: ____________ ______________________________ ______________________________ City: ______________________________ State: ____________ Zip: ____________ Name and address of Guardian: Index No.: _____________ Name of Judge of Justice Appointing Guardian: Date of Order/Judgment Appointing Guardian: Date of Guardian's Initial Report: ______________________________ ______________________________ ______________________________ Present Value of Estate: ______________________________ 1. Was proof of completion of guardian education requirements under MHL § 81.39 filed with initial report? Yes No I - PROPERTY MANAGEMENT* 2. Does report contain an inventory of the property and financial resources over which the guardian has control? Yes No Does report indicate the location of any will executed by the incapacitated person? Yes No Does report set forth the guardian's plan, consistent with the court's order, for management of the property and financial resources of the incapacitated person? Yes No Does report indicate any need for any change in the power authorized by the Court with respect to property management? Yes No If so, explain briefly. 3. 4. 5. * Complete only if guardian has been granted powers with respect to property management REVISED 5/14 American LegalNet, Inc. www.FormsWorkFlow.com II - PERSONAL NEEDS** 6. Does report contain a report of the guardian's personal visits with the incapacitated person? Yes No Does report set forth the steps guardian has taken, consistent with the court's order, to provide for the personal needs to the incapacitated person? Yes No Does report set forth the guardian's plan, consistent with the court's order, for providing for the personal needs of the incapacitated person, including the information set forth in MHL § 81.30 (c) (1-4)? Yes No Does report attach a copy of any directive pursuant to Public Health Law § 2965 (Do Not Resuscitate Order) or § 2981 (Health Care Proxy), any living will, or any other advance directive? Yes No If so, explain briefly. 7. 8. 9. __________________________________________________________________ 10. Does report indicate any need for any changes in the powers authorized by the court with respect to personal needs? Yes No If so, explain brief. __________________________________________________________________ ** Complete only if guardian has been granted powers regarding personal needs. American LegalNet, Inc. www.FormsWorkFlow.com III - APPLICATION FOR CHANGE IN POWERS If report indicates any reasons for a change in the powers authorized by the court, has guardian made application within 10 days of filing of report as required by MHL § 81.30 (d)? If application has not been made, please explain briefly. Yes No __________________________________________________________________ __________________________________________________________________ _________________ Date of this Report ___________________________ (Your signature) ______________________________ ______________________________ City: ______________________________ State: ____________ Zip: ____________ (Your name and address) EXAMINERS' COMPENSATION IS FIXED AT $100, WHICH SHALL BE ORDERED PAID BY THE ESTATE IN ESTATES OF $5,000 OR MORE. IN ESTATES OF LESS THAN $5,000, EXAMINER SHALL SUBMIT STANDARD STATE VOUCHER (see 22 NYCRR 806.17[c]). American LegalNet, Inc. www.FormsWorkFlow.com