Lorain County Probate Court Judge James T. Walther IN THE MATTER OF THE GUARDIANSHIP OF _____________________________________________ CASE NO. _______________________ 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. This is the (circle one) 1st, 2nd, 3rd, 4th, 5th, 6th, or _________, Guardian's Report. 2. Ward's present address: ______________________________________________________________________________ City ______________________________________ State ____________________________ Zip ______________________________ 3. Telephone (______)______________________ 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 of 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. (1) b. Temporarily. The new address and telephone number is: Unknown. I will provide this information when known. (2) ______________________________________________________________________________________ City ____________________________________________________ State ____________________________ Zip ___________________ Telephone (____)____________________________ 17.7 GUARDIAN'S REPORT American LegalNet, Inc. www.FormsWorkFlow.com [Reverse of Form 17.7] 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. 6. 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 covered by this report? Yes No If "yes" is checked, briefly describe the changes. ___________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ 7. The care giver to the ward is Adequate Not 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 or Print Attorney's Name) ____________________________________________ (Type or Print Guardian's Name) _________________________________________ (Street) ____________________________________________ (Street) _________________________________________ (City, State, Zip Code) ____________________________________________ (City, State, Zip Code) (______)________________ _________________ (______)_____________________________________ Telephone Number Supreme Court Registration 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