Guardians Annual Report (6/2018) Page 1 of 3 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF LINN PO Box 1749 Albany Oregon 97321 541 - 967 - 3845 www.courts.oregon.gov/linn In the Matter of: Case No: Na me: Address: Phone: Information regarding Protected Person since the last report: 1. current residence: a. Name (if applicable): b. Address: c. Type of facility or residence: d. Name of the person at the residence who is primarily responsible for care of : e. Name and address of any hospital or other institution where is now admitted on a temporary or permanent basis: 2. is currently engaged in the following programs and activities and receiving the following services: 3. I made the following contacts with during the past year (brief description): American LegalNet, Inc. www.FormsWorkFlow.com Guardians Annual Report (6/2018) Page 2 of 3 4. physical condition is (brief description): 5. mental condition is (brief description): 6. Facts that support the conclusion that is incapacitated include: 7. I was paid for providing the following items of lodging, food, or other services to : 8. I made the following major decisions on behalf of during the past year: 9. Finances - Money received or spent on behalf of (please attach an itemized account for any amounts received or spent) a. I received the following amount of money: b. I spent the following amount of money: c. I now hold the following amount of money: 10. I, or other members of my household, have been convicted of the following crimes (not including traffic violations): (include the name of the applicable person) : American LegalNet, Inc. www.FormsWorkFlow.com Guardians Annual Report (6/2018) Page 3 of 3 11. I have filed for or received protection from creditors (explain): 12. I have had a professional or occupational license revoked or suspended (explain): 13. (explain): 14. I have delegated powers over as follows: a. To (name): b. Powers delegated: c. For how long: I believe the guardianship should should not continue because: I hereby declare that the above statements are true to the best of my knowledge and belief. I understand they are made for use in court and I am subject to penalty for perjury. Date Signature Name (printed) NOTICE: Any person interested in the affairs or welfare of the protected person who is the contact the court as follows: LINN Circuit Court PO Box 1749 Albany Oregon 97321 541-967-3845 www.courts.oregon.gov/linn American LegalNet, Inc. www.FormsWorkFlow.com