SUPREME COURT OF THE STATE OF NEW YORK COUNTY OF NEW YORK --------------------------------------IN THE MATTER OF THE APPLICATION OF IAS Part No. , Index No. Petitioner, FOR THE APPOINTMENT OF A GUARDIAN FOR , INITIAL REPORT OF GUARDIAN An Alleged Incapacitated Person, --------------------------------------, the Guardian in this proceeding, submits this Initial Report of Guardian pursuant to Mental Hygiene Law § 81.30 and states as follows: 1. I reside at . My telephone number is . I was appointed guardian of the person [or property or person and property] of [THE INCAPACITATED PERSON] by Order and Judgment of the Honorable , Justice of the Supreme Court of the State of New York, dated . I received my commission on . 2. I am not related to the incapacitated person [or I am the incapacitated person’s [NAME RELATIONSHIP]]. The incapacitated person’s date of birth is . I shall separately provide to the court’s Guardianship and Fiduciary Support Office (60 Centre Street, Room 148) the incapacitated person’s social security number. 3. I attended the guardianship training course at on [DATE] [ or I did not attend the guardianship training course because ]. I have attached a copy of the certificate evidencing my completion of the course. 4. The incapacitated person is currently living at the following address: . I visited him [ her ] there on the following days: . American LegalNet, Inc. www.FormsWorkFlow.com 5. The incapacitated person’s primary diagnosis is [Set forth the diagnosis of the IP's medical condition] . This statement is based upon [e.g., Doctor’s report] . 6. If the incapacitated person lives in an apartment or a house, list here the name and relationship of all other persons living with the incapacitated person: . 7. If the incapacitated person has home care services, describe the services here and state the number of hours a day each such service is provided: . 2 American LegalNet, Inc. www.FormsWorkFlow.com 8. The incapacitated person has a [ check all that apply ]: G Will G Living Will G Health Care Proxy G Power of Attorney If you are uncertain as to whether any one of these documents exists, please explain: . As to each of the documents listed below, please indicate by marking "Yes," "No," or "NA" [for Not Applicable] whether you have located the document, provided a copy, or filed same with the Surrogate's Court: Determined Location Provided Copy Filed with Surr. Ct. Will Living Will Health Care Proxy Power of Attorney Other Guardians of the Person Answer the Following Questions: 9. I have taken the following steps to ensure that the Incapacitated person has adequate medical, dental, mental health or other health care services [ PLEASE DESCRIBE ] : 3 American LegalNet, Inc. www.FormsWorkFlow.com . 10. The plan to ensure that the incapacitated person has adequate medical, dental, mental health or other health care services in the future is as follows [ PLEASE DESCRIBE ]: . 11. I have taken the following steps to ensure that the incapacitated person has adequate social and personal services (for example, day care and recreation) [ PLEASE DESCRIBE ]: . 12. I have applied for the following health and accident insurance and government benefits on behalf of the incapacitated person [ PLEASE DESCRIBE ]: 4 American LegalNet, Inc. www.FormsWorkFlow.com . 13. There is no need to modify my powers as personal needs guardian [ or the following changes are necessary in my personal needs powers ] [ PLEASE DESCRIBE]]: . Guardians of the Property of the Incapacitated Person Fill In the Following Information 14. I have marshaled the following assets of the incapacitated person: A.(1) Bank Accounts [list the name of the bank, account numbers and amount of money in the account before you closed the account and transferred the money to a guardianship account] : Bank Account Number Amount 5 American LegalNet, Inc. www.FormsWorkFlow.com (2) Guardianship Bank Accounts [list the name of the bank, account numbers and the amount of money currently in the guardianship bank accounts]: Bank Account Number Amount B. Safe Deposit Box [ if the incapacitated person has a safe deposit box, list the name and address of the bank at which it is located] . Have you inventoried the contents of the safe deposit box? GYes GNo. If yes, attach a list of the contents and the appraisal or the approximate value of the contents. C. Stocks and Securities [ if the incapacitated person owns stocks or other securities, list here 6 American LegalNet, Inc. www.FormsWorkFlow.com the name of the company, number of shares, the market value of each security on the date you received your commission, and the broker ] : Company Name Number of Shares Market Value Brokerage Company Name Type of Bonds etc. Market Value Brokerage D. Real Estate [ list the address of the property, give a description of the property [i.e. store, single family house], approximate value of the property on the date you were commissioned, and name of tenants and rental income, if any. Also, write down the date you filed a statement 7 American LegalNet, Inc. www.FormsWorkFlow.com identifying real property with the County Clerk. ] : Address Description Approx. Value Tenants Rental Income Statement E. Personal Property [ list any jewelry, antiques, paintings, automobiles, or other valuable property or cash and set forth the approximate value ] : Property Type Appraised Value Approx. Value 8 American LegalNet, Inc. www.FormsWorkFlow.com F. Income [ set forth here all sources of income for the incapacitated person, i.e. social security, pensions, etc. and the monthly or annual amount received ] : Source of Income Amount G. Assets Not Yet Marshaled [ list all property owned by the incapacitated person that you have not yet been able to transfer to the guardianship ] : 9 American LegalNet, Inc. www.FormsWorkFlow.com . 15. There is no need to modify my powers as property guardian [ or the following changes are necessary to my powers as property guardian [EXPLAIN] : . 16. I G WILL [ or ] G WILL NOT need help preparing my annual report [ CHECK ONE ]. 10 American LegalNet, Inc. www.FormsWorkFlow.com STATE OF NEW YORK ) ) ss.: COUNTY OF NEW YORK) , being duly sworn, states as follows: I am the guardian for the above-named incapacitated person, having been duly appointed by Order and Judgment of the Supreme Court of the State of New York, New York County. The foregoing Initial Report, including the account and inventory therein, contains, to the best of my knowledge and belief, an accurate statement of the facts set forth, as well as a full and true statement of all my receipts and disbursements on account of said 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 or for my use as guardian since my appointment, and of the value of all property. I do not know of any error of omission in the report to the prejudice of the incapacitated person. ___________________________ Guardian Sworn before me this day day of , 20 _________________________________ Notary Public or Commissioner of Deeds 11 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS FOR INITIAL (90-DAY) REPORT This is the report that you must file no later than ninety (90) days after you receive your commission. This report tells the court what you have done so far to help the incapacitated person. To answer Questions 1 through 7, fill in the blanks with the requested information. To answer Question 8, put a circle around all the documents that the incapacitated person has. If the incapacitated person does not have any of the documents, leave this blank. If you are uncertain about the existence of any document, please explain. Also, using “Yes,” “No,” or “NA” [for Not Applicable], please indicate as to each of the listed documents whether you have determined the location thereof, provided a copy, or filed with the Surrogate’s Court (e.g., will). If you were appointed a guardian of the person of the incapacitated person, you must answer Questions 9 through 13. If you were only appointed a guardian of the person’s property, you should skip these questions. Question 9 – Tell the court what you have done so far to provide for the incapacitated person’s medical, dental, mental and other health care needs. (For example: I took the incapacitated person to the eye doctor to get new glasses and to the dentist to have a tooth pulled.) Question 10 – Tell the court what you plan to do in the future to make sure that the incapacitated person has adequate medical, dental, mental health and other health care. (For example: I will bring the incapacitated person to Doctor X for an annual physical and to Doctor Y, a podiatrist, for special shoes.) Question 11 – Tell the court what you have done to make sure that, if feasible, the incapacitated person has an opportunity to be with other people, or work, attend school, or participate in other activities. Question 12 – List the government benefits and/or insurance you have applied for on behalf of the incapacitated person (Medicare, Medicaid, etc.). Question 13 – If you think you need more powers to meet the personal needs of the incapacitated person, or fewer powers, write down the changes you would like to see made and tell the court why you want them. 12 American LegalNet, Inc. www.FormsWorkFlow.com If the court gave you management powers over the incapacitated person’s property, you must answer Question 14, sections A through G, and Question 15. If you are only a guardian of the person, you should not answer these questions. Question 14 (A)(1) – List all the bank accounts that the incapacitated person had when you were appointed guardian, the account numbers and the amount in each account. Question 14(A)(2) – List all of the guardianship accounts that you set up, the name of the bank where they are located, the account number and the amount of money in each account. Question 14(B) – If the incapacitated person had a safe deposit box, provide the requested information. If the incapacitated person did not have a safe deposit box, leave this section blank. Question 14(C) – If the incapacitated person owned shares of stock, provide a complete list of all stock, including the name of the company, the number of shares and the market value of the stock on the date you received your commission. If the incapacitated person owned bonds or other types of securities, provide information regarding the type of security and the market value on the date you received your commission. Please also provide the name of the brokerage house holding the stock, bonds, or other securities. Question 14(D) – Provide the requested information for all real property owned by the incapacitated person. Question 14(E) – Separately list all valuable personal property and provide an appraisal or approximate value if you do not have an appraisal. If the incapacitated person owned ordinary household furnishings and clothing, provide an approximate value for this personal property. Question 14 (F) – List all monthly income (for example, social security, pensions and trust income) and the monthly amount the incapacitated person receives from each source. Question 14(G) – List all of the assets that the incapacitated person owns that you have not yet transferred into guardianship accounts. Question 15 -- If you think you need more power over the incapacitated person’s property, or less power, write down the changes you would like to see made and tell the court why they should be made. 13 American LegalNet, Inc. www.FormsWorkFlow.com Question 16 – If you think you will need assistance preparing the Annual Report, circle “will”. If you think you can do the Annual Report on your own, circle “will not.” When you have answered all the questions, bring this report to a notary public and sign the paragraph at the end (the certification paragraph) in front of the notary and then have the report notarized. You must then mail a copy of the report to: Guardianship and Fiduciary Support Services New York Supreme Court 60 Centre Street, Room 201-B New York, NY 10007 The Court Examiner named in your appointing Order and judgment. The Incapacitated Person The Court Evaluator named in the appointing Order If the incapacitated person lives in a residential facility, to the director of the facility To Mental Hygiene Legal Services if the incapacitated person lives in a Mental Hygiene Facility If you have any questions, please call the Guardianship and Fiduciary Support Office of the New York County Supreme Court at 646-386-3328. Thank you. 14 American LegalNet, Inc. www.FormsWorkFlow.com N o. 1: 10/23/06 15 American LegalNet, Inc. www.FormsWorkFlow.com