DOU*PB-25 rev 1/18 GUARDIANS REPORT ORS125.325 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF DOUGLAS Probate Department In the Matter of the Guardianship of Case No. A Protected Person GUARDIAN222S REPORT I am the guardian for the person named above, and I make the following report to court as required by law My Name is My address and telephone number is: Phone The name, if applicable and address of the place where the person now resides are: The person is currently residing at the following type of facility or residence: The person is currently engaged in the following programs and activities and receiving the following services (brief description) I was paid for providing the following items of lodging, food or other services to the Person: American LegalNet, Inc. www.FormsWorkFlow.com DOU*PB-25 rev 1/18 GUARDIANS REPORT ORS125.325 The name of the person primarily responsible for the care of the person at the Person222s place of residence is: The name and address of any hospital or institution where the person is now admitted on a temporary or permanent basis are: The person222s physical condition is as follows (brief description) The person222s mental condition is as follows (brief description) I made the following contracts with the person during the past year (brief description) I made the following major decisions on behalf of the person during the past year (brief description) I believe the guardianship should or should not continue because: American LegalNet, Inc. www.FormsWorkFlow.com DOU*PB-25 rev 1/18 GUARDIANS REPORT ORS125.325 At the time of my last report, I held the following amount of money on behalf of the person: $ Since my last report, I received the following amount of money on behalf of the person: $ I sp ent the following amount of money on behalf of the person: $ I now hold the following amount of money on behalf of the person: $ A true copy of this report will be given to the person, any conservator for the person and any other person who has requested notice. 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 have had my driver license revoked or suspended (yes or no): Since my last report, I have delegated the following powers over the protected person to the following periods of time (provide name of person powers delegated to): I hereby declare 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 Guardian [If more than one appointed] American LegalNet, Inc. www.FormsWorkFlow.com