SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK I.A. Part -------------------------------------------------------x IN THE MATTER OF THE APPLICATION OF Index No.: , Petitioner, FOR THE APPOINTMENT GUARDIAN FOR OF A ANNUAL REPORT , an Alleged Incapacitated Person. FOR 20 ------------------------------------------------------x , residing at , as Guardian for , who was heretofore determined by this court to be an incapacitated person (“IP”), do hereby make, render and file the following Annual Report. I, On the day of , 20 , I was duly appointed Guardian of the above-named person by Order of the Supreme Court of New York County and have continued to act as such fiduciary since that date, giving a bond in the original sum of $ ,[now in the sum of $ , pursuant to subsequent orders,] which is still in force and effect with , as Surety. There has been no change in the Surety thereon, and the Surety is in as good financial standing as when the bond was given. [There has been no change in the Surety thereon, other than as explained in Schedule F.] 20 The following is a true and full account of all receipts and disbursements for the year . SUMMARY Schedule A - Principal on hand as of Date of Appointment or Last Annual Report $ Schedule B - Changes to Principal $ Schedule C - Income Received $ Sub-Total Schedule D - Paid Disbursements $ $ American LegalNet, Inc. www.FormsWorkFlow.com Schedule E-1 - Balance of Cash and Securities to be Charged to Next Year's Account $ Schedule E-2 - Real Estate $ Schedule E-3 - All Other Personal Property $ Total Estate $ 2 American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE A - PRINCIPAL ON HAND AS OF DATE OF APPOINTMENT OR LAST ANNUAL REPORT SOURCE: Name and address of bank or financial institution TOTAL OF SCHEDULE A AMOUNT (i.e., number of shares) $ 3 American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE B - INCREASES OR DECREASES TO PRINCIPAL (List additional property received, gain or loss on sale or liquidation of stocks or bonds, any net receipts from sale of realty (attach copy of closing statement), etc.) SOURCE AMOUNT TOTAL OF SCHEDULE B $ 4 American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE C - RECEIVED INCOME AND CASH INCREASES (If any property listed in the last Report has been converted to cash, list here the amount received from the sale and attach an explanation. If the Guardian has used or employed the services of the IP, or if moneys have been earned by or received on behalf of the IP, state details and amounts here (See Par. 9, below)): SOURCE AMOUNT TOTAL OF SCHEDULE C $ 5 American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE D - PAID DISBURSEMENTS PAID TO AMOUNT TOTAL OF SCHEDULE D $ 6 American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE E-1 - BALANCE ON HAND AND OTHER PERSONAL AND REAL PROPERTY BANK ACCOUNTS, BROKERAGE ACCOUNTS, PERSONAL PROPERTY, SECURITIES (List names of joint owners, if any, and their relationship to the IP) TOTAL OF SCHEDULE E-1 INVENTORY VALUE MARKET VALUE (List values as of end of accounting period; for securities, list both inventory and market values) $ $ 7 American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE E-2 - REAL ESTATE List all real estate owned in whole or in part by the IP. State location, assessed value, current market value, amount of mortgage (if any), and the weekly or monthly rental. If property is owned jointly, give names of joint owners and their relationship to the IP. LOCATION ASSESSED VALUE MARKET VALUE MORTGAGE RENTAL INCOME JOINT OWNERS TOTAL OF SCHEDULE E-2 Assessed Value: $ Market Value : $ Mortgages: Rental Income: $ $ 8 American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE E-3 - ALL OTHER PERSONAL PROPERTY DESCRIPTION INVENTORY/MARKET VALUE TOTAL OF SCHEDULE E-3 $ 9 American LegalNet, Inc. www.FormsWorkFlow.com SCHEDULE F - NAME AND ADDRESS OF SURETY Attach a copy of the latest bond. Also, state and explain any changes in the bond, of the Surety thereon, or in the financial standing of the Surety.) NAME AND ADDRESS OF SURETY AMOUNT OF BOND BOND NUMBER 10 American LegalNet, Inc. www.FormsWorkFlow.com AS TO THE INCAPACITATED PERSON: 1. State the age, date of birth and marital status of the Incapacitated Person. 2. If any are living, list the name and present address of the spouse, children and siblings of the Incapacitated Person. 3. State the present residence address and telephone number of the Guardian. 4. State the present residence address and telephone number of the Incapacitated Person. If the IP does not currently reside at her/his personal home, set forth the name, address and telephone number of the facility or place at which he/she resides, and the name of the chief executive officer of the facility or the person otherwise responsible for the care of the IP. 11 American LegalNet, Inc. www.FormsWorkFlow.com 5. State whether there have been any changes in the physical or mental condition of the Incapacitated Person, and any substantial change in medication. 6. State the date and place the Incapacitated Person was last seen by a physician and the purpose of that visit. 12 American LegalNet, Inc. www.FormsWorkFlow.com 7. Attach a statement by a physician, psychologist, nurse clinician or social worker, or other qualified person who has evaluated or examined the Incapacitated Person within the three months prior to the filing of this report, setting forth an evaluation of the Incapacitated Person's condition and the current functional level of the Incapacitated Person. 8. If the Guardian has been charged with providing for the personal needs of the Incapacitated Person: (a) Attach a statement indicating whether the current residential setting is suitable to the current needs of the Incapacitated Person. (b) Attach a resume of any professional medical treatment given to the Incapacitated Person during the preceding year. (c) Attach the plan for medical, dental and mental health treatment and related services for the coming year. (d) Attach a resume of any other information concerning the social condition of the Incapacitated Person, including the social and personal services currently utilized by the Incapacitated Person and the social skills and needs of the Incapacitated Person. 9. State whether the Guardian has used or employed the services of the Incapacitated Person, or whether moneys have been earned by or received on behalf of such Incapacitated Person. Provide details in Schedule C. 10. Attach a resume of any other pertinent facts about the care and maintenance of the Incapacitated Person, including the frequency of your visits; whether the Incapacitated Person has made a Will or executed a Power of Attorney; and any other information necessary for the proper administration of this matter. 13 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF NEW YORK ) COUNTY OF ) ) ss.: , being duly sworn, says: I am the Guardian for the above-named Incapacitated Person. The foregoing Annual Report contains, to the best of my knowledge and belief, a full and true statement of all my receipts and disbursements on account of said Incapacitated Person; and of all money and other personal property of said person which have come into my hands or have been received by any other persons by my order or authority since my appointment or since filing my last Annual Report and of the value of all such property, together with a full and true statement and account of the manner in which I have disposed of the same and of all property remaining in my hands at the time of filing this Report; also a full and true description of the amount and nature of each investment made by me since my appointment or since the filing of my last Report. I do not know of any error or omission in the Report to the prejudice of said person. Guardian Sworn to before me this day of , 20 Notary Public 14 American LegalNet, Inc. www.FormsWorkFlow.com