PROBATE COURT OF CUYAHOGA COUNTY, OHIO Anthony J. Russo, Presiding Judge Laura J. Gallagher, Judge IN THE MATTER OF THE GUARDIANSHIP OF ______________________________________ CASE NUMBER ______________________________________ GUARDIAN'S REPORT [R.C. 2111.49] NOTE: If allotted space is inadequate to respond, write “See Exhibit” in the space and add appropriate exhibit letter sequence, then attach exhibit containing information requested for that space. 1. 2. This is the (check one): G1st, G2nd, G3rd, G4th, G5th, G 6th, or ________ , Guardian’s Report Ward’s present address: _________________________________________________________ City _____________________________________________________ 3. Zip _______________ Telephone ( ______ ) ___________________ Ward’s living arrangements at the above address are best described as: G a. His or her own apartment or home (includes assisted living facilites). G b. Private home or apartment of: G (1) the ward’s guardian. G (2) a relative of the ward, whose name is ___________________________________ and relationship is __________________________________________________ G (3) a non-relative whose name is __________________________________________ G c. G d. G e. G f. A foster, group or boarding home. A nursing home. A medical facility or state institution. Other (describe) __________________________________________________________ g. _______________________________________________________________________ If c, d, e, or f is checked, complete the following: (1) The name of the home, facility or institution ___________________________ _________________________________________________________________ (2) The name of an individual at the home, facility or institution who has knowledge and is authorized to give information to the Court about the ward. Name ____________________________________________________________ 4. Telephone Number ( _______ ) ______________________________________ The ward will be at the address given in item 2: G a. G b. Indefinitely. Temporarily. The new address and telephone number is: G (1) Unknown. I will provide this information when known. G (2) _________________________________________________________________ City ___________________________________ State ___________________ Zip ____________________ Telephone ( ________ ) _________________ Form 17.7 - Guardian’s Report American LegalNet, Inc. www.FormsWorkFlow.com 5. Guardian’s contact with the ward: a. Approximate number of times the guardian had contact with the ward during the period covered by this report: _______________________ . b. The nature of those contacts (phone, personal, or other): ____________________ _________________________________________________________________ C. Date the ward was last seen by the guardian: _____________________________ Briefly describe any changes. _________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 6. The care given the ward is G Adequate G Not adequate If “not adequate” is checked, explain. _______________________________________________ _____________________________________________________________________________ ______________________________________________________________________________ 7. The guardianship should be G Continued G Not Continued If “Not Continued” is checked, explain. _____________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 8. During the period covered by this report, the ward G has G has not been seen by a physician. If the ward has been seen, the last date was _________________________ and for the purpose of __________________________________________________________ . Attached is a statement by a licensed physician, a licensed clinical psychologist, a licensed social worker, or a mental retardation team, that has evaluated or examined the ward within three months prior to the date of this report regarding the need for continuing the guardianship. [R.C. 2111.49(A)(1)(i)] (Form 17.1) If an attorney has been consulted on this report ________________________________________________ Date __________________________________________________ _________________________________________________ Attorney’s Signature Guardian’s Signature __________________________________________________ _________________________________________________ (Type or Print Attorney’s Name) (Type or Print Guardian's Name) __________________________________________________ _________________________________________________ (Street) (Street) __________________________________________________ _________________________________________________ (City, State, Zip Code) (City, State, Zip Code) (_______)________________ ______________________ (_______)________________________________________ (Telephone Number - include area code) Supreme Court Registration Number (Telephone Number - include area code) (Knowingly giving false information on a Probate document is a criminal offense.) [R.C. 2921.13(A)(11)] American LegalNet, Inc. www.FormsWorkFlow.com