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Annual Report Of Guardian Form. This is a New York form and can be use in Bronx Local County.
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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
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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.
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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):
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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
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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).
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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.
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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:
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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.
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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
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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.
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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".
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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
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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
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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 ยง 81.20(a)(6)(vi).
SCHEDULE B
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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
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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
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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
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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
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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
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2.
CORPORATION AND GOVERNMENT SECURITIES.
Name of Securities/Bond
Amount
Total
3.
PRESENT OR FUTURE INTERESTS.
Names
Acct #
Amount
Total
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4.
OTHER PERSONAL PROPERTY.
Description of Item
Date of Appraisal
Value
Total
5.
REAL PROPERTY
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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)
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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
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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
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