Page 1 of 4 Form 9.400.1 UTCR 9.400 /1/2018 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF JACKSON 100 S. Oakdale, Medford, OR, 97501 In the matter of the Guardianship of: , Respondent ) Case No: ) ) REPORT ) ADULT GUARDIANSHIP I, , have been appointed as court visitor in the abovementioned proceeding. I.EXPRESSED WISHES OF RESPONDENT / PROCEDURAL RIGHTSYes No A.Does the Respondent object to the appointment of a fiduciary?B.Does Respondent prefer that another person act as fiduciary? The name, address, telephone number, and proposed role ofthe person of preference is:C.If Respondent objects to the appointment of a fiduciary, doesthe Respondent understand that a hearing will be held? If a hearing is scheduled, is the Respondent willing to attend a hearing or totalk to the judge by telephone during the hearing?Does the Respondent wish to be represented by counsel? Attorney Name: F.Does the Respondent wish for the visitor to interview particular individuals? reason for not interviewing, if applicable: Name & Relationship Interviewed? Yes No G.the above questions: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 Form 9.400.1 UTCR 9.400 /1/2018 II.CAPACITYA.Discuss any inability of the Respondent or impairments of the Respondent which mightimpact their ability to provide for their needs with respect to physical health:B.Discuss any inability of the Respondent or impairments of the Respondent which mightimpact their ability to provide for their needs with respect to food/clothing concerns:C.Discuss any inability of the Respondent or impairments of the Respondent which mightimpact their ability to provide for their needs with respect to shelter:D.Please comment if the investigation has determined that the Respondent is unable to resistfraud or undue influence:Yes No E.Do the findings as indicated in "A", "B", and "C" above support theconclusion that the person is incapacitated?If YES, please summarize the relevant facts: EVALUATION OF RESIDENCE, HEALTH CARE, AND SOCIAL SERVICES RECEIVEDIN PAST YEAR: B.Is the Respondent able to live at this residence while under guardianship?C.As per the petitioner, what health and social services or alternatives to guardianship havebeen provided to the Respondent during the year preceding the filing of the petition (ifknown)?D.What Health Care services has the Respondent been receiving over the past year? PleaseExplain: American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 Form 9.400.1 UTCR 9.400 /1/2018 IV.FINDINGS AND RECOMMENDATIONSYes No A.Are the facts stated in the petition substantially correct?B.Have alternatives to guardianship/conservatorship been considered? E.g.,Advance Directive for Health Care, Revocable Trust, Family Assistance, and/ora Durable Power of Attorney? If YES, please describe:C.Is the Respondent so impaired that he/she is unable to make reasoneddecisions about his/her safety?D.Is the appointment of a fiduciary necessary?E.Is it appropriate to limit the scope and/or duration of theIf YES, for what limited purpose(s) and/or duration is a fiduciarynecessary?F.Is the nominated fiduciary(ies)1.A professional fiduciary?2.A family member?Relationship, if family member: 3.Willing to serve?4.Qualified to serve?5.Suitable to serve?If NO to 3, 4, or 5, please describe: G.Did the Respondent object to the appointment of the Fiduciary?If yes, please explain: H.Is there is an objection to the petition from parties other than theRespondent? If yes, please describe the issues?I.If you have identified anyone else you believe is more appropriate for appointment asguardian and/or conservator, please provide the name and reasons for the conclusion: Yes No J.Respondent requested representation by counsel: If yes, please explain: Name of Counsel: American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4 Form 9.400.1 UTCR 9.400 /1/2018 Yes No K.If the Respondent does not wish to be represented, is counselrecommended by the court visitor help resolve issues in the case? If YES, please describe:K.Additional comments that might assist the court and all persons interested in this matter:V.All of the people interviewed by the visitor while compiling this report are listedbelow: Name Address & Phone Relationship Date Interviewed 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. Court Visitor Name Signature of Court Visitor Date NOTICE: Any person interested in the affairs of welfare of the protected person who is the subject of this report who has concerns about this report or the Guardian's performance may contact the Court as follows: Please provide, in writing, your: NameAddressPhone NumberRelation to protected personYour request(s) or concern(s)Deliver to: Jackson County Circuit Court Attn: Probate Department 100 S. Oakdale, Medford, OR, 97501 American LegalNet, Inc. www.FormsWorkFlow.com