IN THE CIRCUIT COURT FOR THE STATE OF OREGON FOR THE COUNTY OF DESCHUTES PROBATE In the Matter of the Guardianship of: ) ) Case No. , ) ) G U ARDIAN'S REPORT A Protected Person. ) I am the guardian for the person named above, and I make the following report to the court as required by law: 1. My name is: 2. My residence address and telephone number ar e: Phone 3. The name, if applicable, and address of the place where the ward now resides are: 4. The person is currently residing at the following type of facility or residence: 5. The person is currently engaged in the following programs and activities and receiving the following services (brief description): 6 . I was paid for providing the following items of lodging, food or other services to the person: 7. The name of the person prim arily responsible for the care of the ward at the ward's place of residence is: 8. The name and address of any hospital or other institution where the person is now admitted on a tempora ry or permanent basis are: American LegalNet, Inc. www.FormsWorkFlow.com 9. A brief description of the ward's physical condition is: 10. A brief description of the ward's mental condition is: 11. Facts that support the conclusion that the person is incapacitated include the following: 1 2 . I made the following contacts with the person during the past year (brief description): 1 3 . I made the following major decisions on the ward's behalf during the past year (brief description): 1 4 . I believe the guardianship should or should not continue because: 1 5 . I received the following amount of money on behalf of the person: $. I spent the following amount of money on behalf of the person: $. I now hold the following amount of money on behalf of the person: $. 1 6 . A true copy of this report will be given to the person, if of the age to understand, any conservator for the person and any other person who has requested notice. 1 7 . Since my last report: ( a) I have been convicted of the following crimes (not including traffic infractions): ( b ) I have filed for or received protection from creditors under the Federal Bankruptcy Code (yes or no): . (c) I have had a professional or occupational license revoked or suspended (yes or no): . (d) I hav e had my drivers license revoked or suspended (yes or no): . 1 8 . Since my last report, I have delegated the following powers over the protected person for the following periods of time (provide name of person powers delegated to): American LegalNet, Inc. www.FormsWorkFlow.com I have given a copy of this report to persons specified in ORS 125.060(3). I hereby declare that the above statement is true to the best of my knowledge and belief and that I understand it is made for use as evidence in court and is subject to penalty for perjury. Dated this day of , 20. Guardian Court contact information: Deschutes County Circuit Court 1100 NW Bond Street Bend OR 97703 (541) 388 - 5300 American LegalNet, Inc. www.FormsWorkFlow.com