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. Accounting Period: ___ to ___ Index No. . --------------------------------------------------------------------------------------General Instructions 1. All guardians must complete Sections I and II 2. All guardians must attach a copy of the order of appointment. 3. If you have been appointed guardian for the personal needs of the incapacitated person, please complete Section III. 4. 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. (b) 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. (c) In any schedule, if there is nothing to list, state "NONE". Revised 12/14/09 American LegalNet, Inc. www.FormsWorkFlow.com 5. If the incapacitated person was a resident of New York City at the time of your appointment, file the original annual report in the office of the Clerk of the County in which the incapacitated person last resided before your appointment. If the incapacitated person was not a resident of New York City at the time of your appointment, the original annual report should be filed in the office of the Clerk of the Court which appointed you as guardian. 6. Send a copy of the annual report to the incapacitated person by mail. If the incapacitated person resides in a facility, hospital, school or alcoholism facility in New York State, a substance abuse program, an adult care facility, a residential health care facility or a general hospital, send a duplicate of the annual report to the chief executive office of the facility and Mental Hygiene Legal Service if the incapacitated person resides in a psychiatric facility: Mental Hygiene Legal Service has an office located at: Marvin Bernstein Director, First Department Mental Hygiene Legal Service 60 Madison Ave. New York, New York 10010 Also send a copy of the annual report to the examiner assigned to your case. The name and address of the examiner for your case may be located in the Order and Judgement or from the Guardianship/Fiduciary Dept. of the Supreme Court, Bronx County by calling (718) 618 1330. American LegalNet, Inc. www.FormsWorkFlow.com SECTION I 1. INFORMATION PERTAINING TO THE GUARDIAN (all guardians must complete this section). REPORT: Date of initial report: Date of last annual report: Date of this report: , through , . Period covered by this report: (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): Telephone no.: 3. APPOINTMENT: Date of order: Court: Name of Judge/Justice: 4. BOND: Bonding company name: Bonding company address: Value of bond (If the bonding requirement was waived, so state): American LegalNet, Inc. www.FormsWorkFlow.com 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: Place Date 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 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: 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). American LegalNet, Inc. www.FormsWorkFlow.com 10. TYPE OF GUARDIANSHIP: Have you been granted powers over the personal needs incapacitated person? Yes of the 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. American LegalNet, Inc. www.FormsWorkFlow.com SECTION II 1. INFORMATION PERTAINING TO THE INCAPACITATED PERSON (all guardians must complete this section) INCAPACITATED PERSON: Name: Address (If residential facility, include name of the Director or person responsible for care): Telephone no.: Has there been any substantial change in the incapacitated person's mental or physical condition? Yes No If yes, please explain: Has there been any substantial change in the incapacitated person's medication? Yes No If yes, please explain: American LegalNet, Inc. www.FormsWorkFlow.com 2. EXAMINATION: Please state the date and place the incapacitated person was last examined or otherwise seen by a physician and the purpose of such visit: Date Physician Purpose Please attach a statement by a physician, psychologist, nurse clinician or social worker, or other person who has evaluated or examined the incapacitated person within three (3) months prior to the filing of this report, regarding an evaluation of the incapacitated person's condition and current functional level. American LegalNet, Inc. www.FormsWorkFlow.com SECTION III PERSONAL NEEDS If you have been granted powers with respect to the personal needs of the incapacitated person, please provide the following information: 1. RESIDENTIAL SETTING: Is the current residential setting suitable to the needs of the incapacitated person? Yes No If no, please explain: 2. TREATMENT: What professional medical treatment, if any, has been given to the incapacitated person during the preceding year? Date Treatment American LegalNet, Inc. www.FormsWorkFlow.com 3. TREATMENT PLAN: Describe the treatment plan for the coming year for the incapacitated person regarding: (a) Medical treatment (b) Dental treatment (c) Mental health treatment (d) Additional related services 4. SOCIAL SKILLS: Please provide information concerning the social condition of the incapacitated person, such as the incapacitated person's social skills and needs and the social and personal services used by the incapacitated person. American LegalNet, Inc. www.FormsWorkFlow.com SECTION IV PROPERTY MANAGEMENT If you have been granted powers regarding the property management of the incapacitated person, please provide the following information, consistent with your order of appointment, pertaining to your fulfillment of your responsibilities to the incapacitated person to provide for property management: 1. Have you identified, traced and collected assets of the incapacitated person since your appointment? Yes No If no, please explain: 2. Have all of the incapacitated person's past and current income tax returns and payments been brought up to date? Yes No If no, please explain: 3. Please complete the following schedules and summary. If you have nothing to list on a schedule, state "NONE". American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE A Assets on Hand at the Beginning of the Accounting Period Please list all assets of the incapacitated person over which you had sole control as guardian as of the beginning of the accounting period. Do not include in this schedule trust principal in which the incapacitated person has an income interest, property under joint control of any court or real property not transferred to the guardian. 1. BANK ACCOUNTS AND CASH - please list the name and address of institutions, account numbers and balance deposited in banks or other financial institutions. Please also list any cash on hand not in bank accounts. Name of Bank Acct # Amount Total American LegalNet, Inc. www.FormsWorkFlow.com 2. CORPORATE AND GOVERNMENT SECURITIES (e.g., CORPORATE STOCKS AND BONDS; FEDERAL, STATE OR MUNICIPAL BONDS AND NOTES) Name of Securities/Bond Amount Total 3. PRESENT OR FUTURE INTERESTS (e.g., INTERESTS IN PARTNERSHIPS, TRUSTS, LITIGATION SETTLEMENT FUNDS OR PENSIONS) - please list the estimated values of all present and future interests the incapacitated person has in property that has not been transferred to your control. Names Acct # Amount Total American LegalNet, Inc. www.FormsWorkFlow.com 4. OTHER PERSONAL PROPERTY - (e.g., FURNITURE, JEWELRY, ARTWORK) - please list and describe other personal property and indicate estimated value. Description of Item Date of Appraisal Value Total 5. REAL PROPERTY - please describe location and type of real property, type of interest and market value. Please also provide the date of filing of a statement identifying the real property with the County Clerk as required by Mental Hygiene Law § 81.20(a)(6)(vi). SCHEDULE B American LegalNet, Inc. www.FormsWorkFlow.com Assets Received During Accounting Period Please list all principal assets received during the period of this report (show date received, source and amount or value). Name of Bank/Securities Account # Amount Total SCHEDULE C American LegalNet, Inc. www.FormsWorkFlow.com Income Received During Accounting Period Please list all income received during the period from property interests listed in Schedules A and B (show date received, source and amount). Source of Income Nature of item Amount Total American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE D Losses Incurred During Accounting Period Please list all realized losses incurred on principal assets, whether due to sale or liquidation, indicating the asset involved, the date and amount of loss. Name of Securities Date of Sale Amount Total American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE E Moneys Paid Out During Accounting Period Please list all disbursements, excluding investments, during the period, including date of payment, payee and amount. Date Check # Payee Purpose Amount American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE F Assets On Hand At End Of The Accounting Period Please list assets of the type listed in Schedule A on hand at the end of the period and value thereof (see Schedule A for further instructions) 1. BANK ACCOUNTS AND CASH. Name of Bank Acct # Amount Total American LegalNet, Inc. www.FormsWorkFlow.com 2. CORPORATION AND GOVERNMENT SECURITIES. Name of Securities/Bond Amount Total 3. PRESENT OR FUTURE INTERESTS. Names Acct # Amount Total American LegalNet, Inc. www.FormsWorkFlow.com 4. OTHER PERSONAL PROPERTY. Description of Item Date of Appraisal Value Total 5. REAL PROPERTY American LegalNet, Inc. www.FormsWorkFlow.com SUMMARY PART I. Total beginning balance, as shown on Schedule A, $_____________ Total additional assets, as shown on Schedule B, $_____________ Total income received during accounting period, as shown on Schedule C $_____________ TOTAL PART I: $_____________ PART II. Total losses during accounting period, as shown on Schedule D $_____________ Total moneys paid out during accounting period, as shown on Schedule E $_____________ TOTAL PART II: BALANCE ON HAND AT END OF ACCOUNTING PERIOD (Total Part I minus Total Part II) $ ____________ $ ____________ (This amount should be the same as Schedule F) American LegalNet, Inc. www.FormsWorkFlow.com VERIFICATION STATE OF NEW YORK ) ss: COUNTY OF ) , being duly sworn, states that I am the Guardian of the within named incapacitated person and that the attached annual report and schedule(s) are, to the best of my knowledge and belief, a complete and true statement of my activities as such Guardian; receipts and payments on behalf of such incapacitated person; money and other property which has come into my possession or has been received by others pursuant to my order or authority since the date of my appointment or last report; and the value of such property. I do not know of any error or omission in the report or schedule(s) to the prejudice of such incapacitated person. Guardian (Your name, address and telephone number) Sworn to before me this , 20 of day . Notary Public American LegalNet, Inc. www.FormsWorkFlow.com Affidavit of Mailing I, the undersigned, being sworn, say On the day of ,20 I delivered the within Annual Report of Guardian by mailing a true copy to each person named below at the address indicated: *List parties and their addresses here _________________________ Print name below signature Sworn before me on the __________day of _______, 20_____ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com