IN THE CIRCUIT COURT OF THE STATE OF OREGON THIRD JUDICIAL DISTRICT Probate Department In the Matter of the (co-)Guardianship of: ) ) ) ) ) ) ) Case No._________________ GUARDIAN'S REPORT ______________________________________ A Minor, Protected Person. I am (We are) the guardian(s) for the person named above, and I make the following report to the court as required by law: 1. 2. 3. 4. My/our name(s) is:__________________________________________________________ My/our address is:__________________________________________________________ My /our telephone is:___________________ 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 (We were) paid for providing the following items of lodging, food or other services to the person: __________________________________________________________________________ __________________________________________________________________________ The name of the person primarily responsible for the care of the person at the person's place of residence is:_______________________________________________________________ The name and address of any hospital or other institution where the person is now admitted on a temporary or permanent basis are:___________________________________________ ___________________________________________________________________________ The person's physical condition is as follows:______________________________________ ___________________________________________________________________________ The person's mental condition is as follows:_______________________________________ ___________________________________________________________________________ I/We made the following contacts with the person during the past year (brief description): _____________________________________________________________________ 5. 6. 7. 8. 9. 10. 11. GUARDIAN'S REPORT - Page 1 of 2 FC (9/26/12) 12. 13. 14. I/We made the following major decisions on behalf of the person during the past year (brief description):_________________________________________________________________ I/We believe the guardianship should should not continue because:________________ ___________________________________________________________________________ At the time of my/our last report, I/We held the following amount of money on behalf of the person: $ . Since my last report, I/We have received the following amount ofmoney on behalf of the person: $ . I/We spent the following amount of money on behalf of the person: $ . I/We now hold the following amount of money on behalf of the person: $ . Since my/our last report: (A) I/We have been convicted of the following crimes (not including traffic violations): none (B) I/We have filed for or received protections from creditors under the Federal Bankruptcy Code: yes / no (C) I/We have had a professional or occupational license revoked or suspended: yes / no (D) I/We have had my driver license revoked or suspended: yes / no Since my/our last report, I/We have delegated the following powers over the protected person for the following periods of time (provide name of person powers delegated to):___________ ___________________________________________________________________________ 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. 15. 16. 17. I/We 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 _________________________________ Co-Guardian GUARDIAN'S REPORT - Page 2 of 2 FC (9/26/12)