REPORT Page 1 of 3 5/4/18 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF JACKSON In the matter of the Guardianship of , CASE NO: (Name of protected person) REPORT 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 address and telephone number are: Phone 3. The name, if applicable, and address of the place where the person 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. place of residence is: American LegalNet, Inc. www.FormsWorkFlow.com REPORT Page 2 of 3 5/4/18 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. 10. description): 11. Facts that support the conclusion that the person is incapacitated include the following: 12. I made the following contacts with the person during the past year (brief description): 13. I made the following major decisions on behalf of the person during the past year (brief description): 14. I believe the guardianship should or should not continue because: 15. 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: $ . American LegalNet, Inc. www.FormsWorkFlow.com REPORT Page 3 of 3 5/4/18 16. A true copy of this report will be given to the protected person, any conservator for the person, and any other person who has requested notice or is required to receive service per ORS 125.060(3). 17. 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 No (c) I have had a professional or occupational license revoked or suspended: Yes No (d) suspended: Yes No 18. Since my last report, I have delegated the following powers over the protected person for the following periods of time (provide the name(s) of person(s) powers were delegated to): I am the guardian herein and I hereby declare that the above statement is true to the best of my knowledge and belief. I understand that it is made for use as evidence in court and is subject to penalty for perjury. DATED this day of , . Signature Print Name: Notice: Any person interested in the affairs or welfare of the protected person who is the subject of court as follows: Please provide, in writing, your: Deliver to: Name Jackson County Circuit Court Address Attn: Probate Dept. Phone # 100 S. Oakdale Relation to Protected Person Medford, OR 97501 Your Requests and Concerns American LegalNet, Inc. www.FormsWorkFlow.com Proof of Mailing s Report Page 1 of 1 5/4/18 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF JACKSON In the matter of the Guardianship of , CASE NO: Protected Person PROOF OF MAILING I, , Guardian for the Protected Person named above declare as follows: , to each of the following persons or entities at their last known mailing addresses as follows: Protected Person (Over 14) Agency Co-guardian (if one) Interested Party Conservator (if one) Other (if one) I hereby declare that the above statement is true to the best of my knowledge and belief. I understand that it is made for use as evidence in court and is subject to penalty for perjury. Dated this day of , 2 . Guardian American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 1 5/4/18 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF JACKSON In the matter of the Guardianship of , CASE NO: (Name of protected person) ORDER APPROVING G REPORT The is hereby: Approved Denied and a show cause hearing shall be set. Certificate of Readiness This proposed order is ready for judicial signature because this order is being submitted after proper notice to interested parties has been given and no objections have been filed. Signature Date Print Name Address (or contact address) City, State, Zip Telephone American LegalNet, Inc. www.FormsWorkFlow.com