INITIAL REPORT OF GUARDIAN COURT OF STATE OF NEW YORK COUNTY OF in the Matter of the Initial Report of As Guardian for An Incapacitated Person Index No. General Instructions 1 2. 3. 4. All guardians must complete Section I. 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 II. If you have been appointed guardian for the property management of the incapacitated person, please complete Section III, the summary and attached schedules pertaining to the guardianship assets and financial resources. (a) When listing property on a schedule, please be specific. For instancewith 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. If a schedule does not provide enough space, attach additional sheets with a reference to the schedule to which the information applies. In any schedule, when there is nothing to list, state ''NONE''. (b) (c) Revised 06/05 American LegalNet, Inc. www.FormsWorkflow.com 5. The initial report must be filed no later than ninety (90) days after the issuance of your commission as guardian. File the initial report with the court that appointed you as guardian. A copy of the initial report must be sent to the incapacitated person by mail, the court evaluator and counsel for the incapacitated person, unless the court has ordered otherwise. If the incapacitated person resides in a facility, send a duplicate of the initial report to the chief executive officer of that facility. If the incapacitated person resides in a mental hygiene facility, send a duplicate of the initial report to the Mental Hygiene Legal Service of the Judicial Department in which the residence is located. A copy of the report must also be sent 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 1 2. GENERAL INFORMATION (all guardians must complete this section). DATE OF THIS REPORT: GUARDIAN: Name: Address (include mailing address, if different): State: Zip : - Telephone no.: 3. ( ) - INCAPACITATED PERSONName: Address (if a residential facility, include name of director or person responsible for person's care): State: Zip : - Telephone no.: ( ) - Revised 06/05 American LegalNet, Inc. www.FormsWorkflow.com 4. APPOINTMENT: Date of order Court: Name of Judge/Justice: 5. BOND: Bonding company name: Bonding company address: State: Zip : - Value of bond (If the bonding requirement has been waived, so state): 6. EDUCATIONAL REQUIREMENTS: Have you fulfilled the educational requirements set forth in Mental Hygiene Law § 81.30(a) by completing a training program approved by the chief administrator? Yes No Have the educational requirements been waived by the court? Yes No If you have not fulfilled the educational requirements and the requirements have not been waived by the court, please explain: Revised 06/05 American LegalNet, Inc. www.FormsWorkflow.com 7. 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 location of such visits: DATE LOCATION If no, please explain: 8. TYPE OF GUARDIANSHIP: Have you been granted powers over the personal needs of the incapacitated person? Yes No If yes, please complete Section II. Have you been granted powers regarding property management of the incapacitated person? Yes No If yes, please complete Section III. Revised 06/05 American LegalNet, Inc. www.FormsWorkflow.com 9. CHANGE IN POWERS: Is there any reason for any alterations in your powers as guardian as authorized by the order appointing you? 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 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, the guardian, and the persons entitled to such notice as stated in the order of appointment. SECTION II PERSONAL NEEDS If you have been granted powers with respect to personal needs of the incapacitated person, please provide the following information, consistent with the order appointing you: 1 Please explain the steps you have taken, consistent with the order appointing you, to provide for the personal needs of the incapacitated person. 2. Please describe the plan for providing for the personal needs of the incapacitated person by setting forth information regarding: (a) Provisions for medical, dental, mental health, or related services: (b) Provisions for any personal and social services: Revised 06/05 American LegalNet, Inc. www.FormsWorkflow.com (c) Medical, dental and mental health examinations necessary to determine the health needs of the incapacitated personDATE Type of Examination Diagnosis/Treatment (d) Utilization of health and accident insurance and any other private or government benefits to which the incapacitated person may be entitled: (e) Any additional provisions of the plan for providing for the personal needs of the incapacitated person: Revised 06/05 American LegalNet, Inc. www.FormsWorkflow.com 3. Please indicate whether the incapacitated person has any of the following. If so, attach a copy to this report: (a) living will (b) health care proxy Yes Yes No No Yes No No (c) surrogate decision-making directive (d) any other advance directive Yes SECTION III PROPERTY MANAGEMENT If you have been granted powers regarding the property management of the incapacitated person, please provide the following information, consistent with the order which appointed you, pertaining to the fulfillment of your responsibilities to the incapacitated person to provide for property management. 1 Please describe the plan for the management of the property and financial resources of the incapacitated person. 2. Has the incapacitated person executed a will? Yes No If yes, please provide location of will. 3. Please complete the following schedules and summary. If you have nothing to list on a schedule, state ''NONE'