PROBATE COURT OF SHELBY COUNTY, OHIO WILLIAM R. ZIMMERMAN, JUDGE 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. 2. 3. This is the (circle one) 1st, 2nd, 3rd, 4th, 5th, 6th, or : , Guardian's Report. Ward's present address: City State Telephone( Zip ) 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. d. e f. A foster, group or boarding home. A nursing home. A medical facility or state institution. g. If c, d, e or f is checked, complete the following: (1) The name of the home, facility or institution Other (describe) (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. a. Indefinitely. b. Temporarily. The new address and telephone number is: (1) Unknown. I will provide this information when known. (2) City Zip Page 1 of 2 State Telephone ( FORM 17.7 - GUARDIAN'S REPORT ) 09/01/91 American LegalNet, Inc. www.FormsWorkflow.com CASE NO. 5. Guardian's contact with the ward: Approximate number of times the guardian had contact with the ward during the period a. covered by this report: b. The nature of those contacts (phone, personal, or other): C. Date the ward was last seen by the guardian: 6. Have you observed any major change in the ward's physical or mental condition during the Yes period covered by this report? No If ''Yes'' is checked, briefly describe the changes. 7. The care given to the ward is If "Not Adequate" is checked, explain. Adequate Not Adequate 8. The guardianship should be If ''Not Continued'' is checked, explain. Continued Not Continued 9. During the period covered by this report, the ward has been seen by a physician. If the ward has been seen, the last date was has not 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)] (H.C. Form 17.15) 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 Page 2 of 2 ( ) Supreme Court Regis. No. (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