IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF DESCHUTES PROBATE DEPARTMENT In The Matter of the Guardianship of ) ) , ) Case No. (Name of Protected Person) ) ) REPORT A Protected Person ) I am the guardian for the person names 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 are: 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 primarily responsiis: 8. The name and address of any hospital or other institution where the person is now admitted on a temporary or permanent basis are: 9. A brief descr 10. A b American LegalNet, Inc. www.FormsWorkFlow.com 11. I made the following contacts with the person during the past year (brief description): 12. 13. If a minor child, provide the name, address and phone number of the school the minor child is school): 14. s are below a C, or if there are any areas of concern noted by a teacher, principal, or school counselor, please explain what steps have been taken to provide assistance to the minor child (if assistance has not been provided, you may be required to attend a court hearing to explain why): 15. If the child is home-schooled provide a brief explanation of why (you may be required to be present for a court hearing to explain the necessity of home-schooling): 16. I believe the guardianship should or should not continue because: 17. I received the following amount of money on behalf of the person: $. I spent the following amount of money on behalf of the person: $. 18. 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. 19. Since my last report: (a) I have been convicted of the following crimes (not including traffic infractions): Please be advised that a criminal history report will be conducted to verify this information. You are required to sign the Release to Obtain Information listed below. Any adult living in the same residence as the ward will need to sign a separate Release to Obtain Information form that will be provided by the Court. (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) American LegalNet, Inc. www.FormsWorkFlow.com 20. 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): 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/Proposed Guardian American LegalNet, Inc. www.FormsWorkFlow.com