PROBATE COURT OF WOOD COUNTY, OHIO David E. Woessner, Judge In the Matter of the GUARDIANSHIP of: __________________________________________________________ Case No.________________________ Date: ________________________ 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 _________________ 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 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) _________________________________________________________________ __________________________________________________________________________________ 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 Phone FORM 17.7 - GUARDIAN’S REPORT Crensch$\forms\17.7 7/26/01 American LegalNet, Inc. www.USCourtForms.com 4. The ward will be at the address given in Item 2: a. b. Temporarily, the new address and telephone number is: City _______________________________ State ________________________ Zip _________________ Telephone (____) ________________ c. 5. Indefinitely. Unknown, I will provide this information when known. Guardian's contact with the ward: a. b. The nature of those contacts (phone, personal, or other): _________________________________ c. 6. Approximate number of times the guardian had contact with the ward during the period covered by this report: _________________________________________________________________________ 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 given to the ward is: Adequate Not Adequate If "Not Adequate" is checked, explain:_____________________________________________________ l ___________________________________________________________________________________ 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 purposes 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 Typed or Printed Name Address: Typed or Printed Name Address: Phone Number (include area code) Phone Number (include area code) Attorney Registration Number (Knowingly giving false information on a Probate document is a criminal offense.) [R.C. 2921.13(A)(11)] American LegalNet, Inc. www.USCourtForms.com