SUPREME COURT OF THE STATE OF NEW YORK ____________________________COUNTY County --------------------------------------------------------------------X In the Matter of __________________________________. Name of Incapacitated Person (“IP” designates Incapacitated Person in this report) --------------------------------------------------------------------X INITIAL REPORT INDEX NO. _______________________ Please mark appropriate boxes with [ X ], and type or print all requested information. For more space, please use reverse side of page of question being answered.. DATE OF ORDER APPOINTING GUARDIAN:_ APPOINTING JUDGE: PERSONS FILING THIS REPORT: What is the status of your educational requirements under MHL § 81.30? _____________________________________________________________________________ Name Address Waived Completed G G G G G G G G _____________________________________________________________________________ Phone Relationship _____________________________________________________________________________ Name Address _____________________________________________________________________________ Phone Relationship _____________________________________________________________________________ Name Address _____________________________________________________________________________ Phone Relationship _____________________________________________________________________________ Name Address _____________________________________________________________________________ Phone Relationship FILING STATUS OF PERSON FILING THIS REPORT: A. G Sole Guardian of Person D. G Co-Guardians of Person B. G Sole Guardian of Property E. G Co-Guardians of Property C. G Sole Guardian of Person and Property F. G Co-Guardians of Person and Property -1American LegalNet, Inc. www.FormsWorkFlow.com INCAPACITATED PERSON’S PERSONAL DATA: 1. IP’s Age: 2. IP resides in: a. G Community at: Address Phone G This address is the IP’s own home, which is G rented G The IP lives here alone. G The IP lives here with others: Years in residence G owned. Name Relationship Name Relationship G This address is the home of another. Name b. Relationship G Facility: Facility Name _________________________________________________________________________________ FAX Date Admitted Name of Social Worker Phone 3. Language of IP: 4. Citizenship: Address G English G Spanish G Other G US G Other PERSONAL NEEDS (Complete if your filing status is A, C, D or F) 5. Primary Care Physician: Name Address Frequency of examinations Date of last examination Phone Primary Diagnosis 6. Psychiatrist/Psychologist or Other Mental Health Provider: Name Address Frequency of examinations Phone Date of last examination Primary Diagnosis 7. Dentist: Name Frequency of examinations Address Phone Date of last examination Complete the following ONLY if the IP resides IN THE COMMUNITY. 8. Pharmacy: Name Address Phone -2American LegalNet, Inc. www.FormsWorkFlow.com 9. List professionals and service agencies (e.g., geriatric care managers, social workers, home healthcare agencies, social service agencies, “meals on wheels”) assisting IP. Name Address Phone _ Profession/Service Name Address Phone _ Profession/Service Name Address Phone _ Profession/Service Name Address Phone _ Profession/Service 10. List Day Care Programs or other regularly attended programs for nutrition, rehabilitation, socialization, etc.. Name Address Phone ______ __ _ Frequency of Attendance Name Address Phone ______ _ Frequency of Attendance Name Address Phone _ Frequency of Attendance Name Address Phone Frequency of Attendance PROPERTY/FINANCIAL MANAGEMENT Complete if your filing status is B, C, E or F. Report all liquid assets, personal property, real property and income you are AUTHORIZED to take into your possession, management and control, AS GUARDIAN. 11. Liquid Assets: a. [ ] Cash Accounts: Have you changed the title of accounts to your name, as guardian? [ Acct. Type/Acct. No. Acct. Type/Acct. No. ] No ] Yes [ ] No ] Yes [ ] No Amount Institution [ Amount Institution ] Yes [ Acct. Type/Acct. No. ] No Amount Institution [ [ Acct. Type/Acct. No. ] Yes [ Institution Amount TOTAL -33 American LegalNet, Inc. www.FormsWorkFlow.com (Accounts in any one institution should not exceed $100,000 in order to avoid the loss of FDIC coverage.) b. [ ] Mutual Funds, Securities and Brokerage Accounts: Have you changed the title of accounts to your name, as guardian? [ Acct. Type/Acct. No. Acct. Type/Acct. No. ] No ] Yes [ ] No ] Yes [ ] No Amount Institution [ Amount Institution ] Yes [ Acct. Type/Acct. No. ] No Amount Institution [ [ Acct. Type/Acct. No. ] Yes [ Institution Amount TOTAL c. [ ] Stocks Have you changed the title on certificates to your name, as guardian? [ [ ] No ] Yes [ ] No ] Yes [ ] No [ ] Yes [ ] No [ ] Yes [ ] No [ No. of shares ] Yes ] Yes [ ] No Value Corporation ] No [ No. of shares [ Value Corporation ] Yes [ No. of shares ] No Value Corporation [ [ No. of shares ] Yes] [ Corporation Value TOTAL d. [ ] Bonds: Have you changed the title on bonds to your name, as guardian? Issuing govt./agcy./corp. Value Issuing govt./agcy./corp. Value Issuing govt./agcy./corp. Value Issuing govt./agcy./corp. Value TOTAL -44 American LegalNet, Inc. www.FormsWorkFlow.com e. Other: list any other liquid asset, giving type, location and value : Have you changed title to these assets to your name, as guardian, or not applicable (N/A)? [ ] Yes Type Location Type Location Location Value Type Location [ ] N/A Value Type [ ] No Value Value [ ]Yes [ ] No [ ] N/A [ ] Yes [ ] No [ ] N/A [ [ ] No [ ] N/A ] Yes TOTAL f. TOTAL VALUE OF LIQUID ASSETS: BOX A 12. Personal Property (e.g., cars, boats, furniture, jewelry, artwork) : Description Location Value Description Location Value Description Location Value Description Location Value Description Location Value Description Location Value Description Location Value Description Location Value TOTAL VALUE OF PERSONAL PROPERTY: BOX B -55 American LegalNet, Inc. www.FormsWorkFlow.com 13. Real Property (e.g., vacant land, residential [including cooperative apartments and condominiums] commercial or income producing property): In the letter you received at your appointment, you were instructed about filing the “Statement Identifying Real Property” (Form #3 attached to letter). Attach a copy of form(s) filed for property listed below. [ ] sole [ ] joint [ ] part*** ( Property Type Property Type *** “Part” includes IP’s part ownership or mortgage interest. and “%” mortgage interest. %) Value **Only give value of IP’s ownership share or mortgage ( Value Location %) Value Location ( [ ] sole [ ] joint [ ] part Property Type %) Value Location ( [ ] sole [ ] joint [ ] part Property Type %) Value Location ( [ ] sole [ ] joint [ ] part Property Type %) Value** Location ( [ ] sole [ ] joint [ ] part Property Type %)**** [ ] sole [ ] joint [ ] part Location TOTAL VALUE OF REAL PROPERTY: **** “%” includes IP’s part ownership or mortgage interest. Mortgage % is proportion of debt to total value. BOX C ESTATE VALUE 14. TOTAL VALUE OF LIQUID ASSETS, PERSONAL AND REAL PROPERTY: (ADD BOXES A, B and C) 15. Regular Monthly Income a. [ ] Social Security Retirement ..............................................................$ per month. b. [ ] Supplemental Security Income (SSI)...............................................$ per month. c. [ ] Social Security Disability (SSD).......................................................$ per month. d. [ ] Veterans’ Benefits (VA)....................................................................$ per month. e. [ ] Pension/Retirement Benefits...........................................................$ per month. f. [ ] Annuity Income................................................................................$ per month. g [ ] Rental Income................................................................................$ per month. -66 American LegalNet, Inc. www.FormsWorkFlow.com h. [ ] Mortgage Interest Income................................................................$ i. [ ] Other from list on reverse side........................................................$ per month. per month. TOTAL REGULAR MONTHLY INCOME: 16. Other Income (report approximate amounts on an annual basis): a. [ ] Interest..............................................................................................$ b. [ ] Dividends..........................................................................................$ c. [ ] Trust Income.....................................................................................$ d. [ ] Other from list on reverse side..........................................................$ TOTAL OTHER INCOME: 17. [ ] IP is the beneficiary of the following trusts: Type Name of Trustee Trustee’s Address/Phone Type Name of Trustee Trustee’s Address/Phone Type Name of Trustee Trustee’s Address/Phone Type Name of Trustee Trustee’s Address/Phone 18. Debt (List all debt over $500): a. [ ] Mortgage(s) (Total balance due on all mortgages)........................$ b. [ ] Rent arrears (Total of past du rent)................................................$ c. [ ] Utilities (Total of past due gas, electric, oil, telephone bills)...........$ d. [ ] Real Property Taxes (Total of past due real property tax).............$ e. [ ] Hospital/Medical (Total of past due hospital, doctor, lab bills)........$ f. [ ] Income Taxes (Total of federal/state/local income taxes...............$ g. [ ] Other from list on reverse side.......................................................$ TOTAL DEBT: -77 American LegalNet, Inc. www.FormsWorkFlow.com 19. Application has been made for the following government entitlements: a. [ ] Social Security Retirement f. [ ] STAR (relief from property taxes) b. [ ] Supplemental Security Income (SSI) g. [ ] Other (please explain) c. [ ] Social Security Disability (SSD d. [ ] Medicaid e. [ ] HEAP (aid for heating costs) 20. Are any civil judicial proceedings pending or threatened against the IP (e.g., mortgage foreclosure, eviction, debt collection, divorce, immigration proceeding; please explain): 21. [ ] Medical/Hospital insurance has been provided for the IP, as follows (please explain): 22. [ ] Homeowner/Renter’s insurance has been provided for the IP, as follows (please explain): 23. [ ] Auto insurance has been provided for the IP, as follows (please explain): 24. [ ] Other insurance has been provided for the IP, as follows (please explain): ___ -88 American LegalNet, Inc. www.FormsWorkFlow.com 25. [ ] Safe Deposit Boxes are authorized to be opened and have been located, as follows: [ [ [ 26. [ ] Opened (inventory attached) Address/Phone Institution ] Opened (inventory attached) Address/Phone Institution ] Opened (inventory attached) Address/Phone Institution ] Opened (inventory attached) [ Institution Address/Phone ] Mail is authorized to be collected and opened and arrangements are, as follows (please explain): _ 27. [ ] Income tax authority has been granted and arrangements to exercise that authority are, as follows (e.g., tax returns filed previously have been located, accountant previously retained to prepare returns has been contacted, IRS FORM 4506 (Request for Copies of Tax Returns) has been filed, IRS FORM 56 (Notice of Fiduciary Relationship) has been filed, IRS FORM SS-4 (Request for Employer Identification Number, if employing persons to assist IP) has been filed, similar state and local forms have been filed; please explain): The following must be completed by ALL GUARDIANS DOCUMENTS 28. The following documents have been found (e.g., power of attorney, health care proxy, will); if any document is inconsistent with the powers granted in the guardianship (e.g., power of attorney grants same property management powers as the guardianship of property or health care proxy grants same medical decision making as guardianship of personal needs), application will be made to the court for further instructions; please mark box if fiduciary (e.g., attorney-in-fact, health care agent, executor/trix) has been given NOTICE of guardianship appointment: Document Type Date Located [ [ ] Application to court required ] NOTICE given to fiduciary Document Type Date Located [ [ ] Application to court required ] NOTICE given to fiduciary Document Type Date Located [ [ ] Application to court required ] NOTICE given to fiduciary Document Type Date Located [ [ ] Application to court required ]NOTICE given to fiduciary Document Type Date Located [ [ ] Application to court required ] NOTICE given to fiduciary -99 American LegalNet, Inc. www.FormsWorkFlow.com VISITS 29. The frequency of the Guardian/Co-Guardians’ visits to the IP and the date of the last visit (Guardians are required to visit at least 4 times per year): (Frequency (e.g., daily, weekly, monthly, 4 Xs per year) Date of last visit CHANGES AND ADDITIONAL POWERS 30. Please report any changes to the IP’s personal care and maintenance or management of his/her financial and property affairs currently needed and planned. 31. Do these changes require additional powers or a modification of the powers granted? DATED: STATE OF NEW YORK COUNTY OF ) ) ) ss: County I/We, being duly sworn, say, that I am/we are the Guardian/Co-Guardians for Name of IP and have executed this Initial Report, which to the best of my/our knowledge and belief contains true and accurate information regarding the personal needs and/or property of the Incapacitated Person and all of the activities I/we have undertaken on behalf of the Incapacitated Person. I/we verify that all matters reported herein are known to me/us of my/our own knowledge, except those which are stated upon information and belief. Sign: Sign: Print Name of Guardian/Co-Guardian of [ ] Person [ ] Property [ ] Person & Property _________________________________________ Print Name of Co-Guardian [ ] Person [ ] Property [ ] Person & Property Sign: Print Name of Co-Guardian [ ] Person [ ] Property [ ] Person & Property Sworn to before me FILERS & JOINT FILERS All filers may only mark one (1) box under their name. To qualify as joint-filers, the same box must be marked under each joint-filer’s name. On this ________day of ___________, 20_____ Affidavit of Mailing -1010 American LegalNet, Inc. www.FormsWorkFlow.com I, the undersigned, being sworn, say On the day of ,20 I delivered the within Initial 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 -1111 American LegalNet, Inc. www.FormsWorkFlow.com