TED KLAMMER, JUDGE PROBATE COURT OF LAKE COUNTY, OHIO IN THE MATTER OF _____________________________________________________ Case No. _________________ Docket ___________________ Page ________________ 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 containing information requested for that space. 1. This is the (circle one): 1st, 2nd, 3rd, 4th, 5th, 6th, or _______ , Guardian’s Report. 2. Ward’s present address: _________________________________________________ City ____________________________ State _____________ Zip ________________ Telephone ( ____ ) ______________ 3. Ward’s living arrangements at the above address are best described as: a. His or her own apartment or home (includes assisted living facilities). b. Private home or apartment of: (1) the ward’s guardian. (2) a relative or the ward whose name is _____________________ and relationship is ______________________________________ (3) a non-relative whose name is ___________________________ c. A foster, group or boarding home. d. A nursing home. e. A medical facility or state institution. f. 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 _____________________________________________ Telephone Number ( _____ ) ___________________________ 4. The ward will be at the address given in Item 2: a. Indefinitely. b. Temporarily. The new address and telephone number is: (1) Unknown. I will provide this information when known. (2) ___________________________________________________ City ______________________________ State _______________ Zip _________________ Telephone ( ____ ) ________________ 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. c. 6. The nature of those contacts (phone, personal, or other): _________________ _______________________________________________________________ Date the ward was last seen by the guardian: __________________________ Have you observed any major change in the ward’s physical or mental condition during the period Yes No covered by this report? If “yes” is checked, briefly describe the changes. _____________________________ __________________________________________________________________________________ ________________________________________________________ 7. The care given to the ward is: Adequate No Adequate If “Not Adequate” is checked, explain. _____________________________________ __________________________________________________________________________________ ________________________________________________________ 8. The guardianship should be: Continued Not Continued If “Not Continued” is checked, explain. ____________________________________ __________________________________________________________________________________ ________________________________________________________ 9. During the period covered by this report, the ward: has 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 Attorney’s Name) ______________________________ (Type Guardian’s Name) ______________________________ (Street) ______________________________ (Street) ______________________________ (City, State, Zip Code) ______________________________ (City, State, Zip Code) ( ____ )____________ _______________ Telephone Number Sup. Ct. Regis No. ( ___ ) ________________________ Telephone Number (Knowingly giving false information on a Probate document is a criminal offense.) [R.C. 2921.13(A)(11)] American LegalNet, Inc. www.FormsWorkFlow.com