PROBATE COURT 1021 SW Fourth Avenue, Room 224 Portland, OR 97204-1123 503/988-3016 GUARDIANSHIP REPORT Minor’s Name: ______________________________ Case Number:_______________________ Minor’s Date of Birth: __________ Date of Guardian’s Appointment: ______________ (Report due on anniversary each year) (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) The address of the minor is: The telephone number for the minor’s residence is:_________________________ The address of the Guardian is:_________________________________________ The telephone number for the Guardian is: How is this household financially supported: __________________________________________________________________ Is the minor still residing with you? _____yes _____no If not, tell us with whom the child is living, the relationship of that person to the child, and why the child is no longer living with you: ____________________________________________________________ ____________________________________________________________ ____________________________________________________________ How long has the minor lived with someone else? Please list the names and occupations or means of financial support of other people living in the same household as the child: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Please tell us about the child’s school attendance and grades:_________________ __________________________________________________________________ __________________________________________________________________ Please tell us about any special awards or accomplishments made by the child during the past year, or describe any disciplinary action by school personnel: __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Please list any medical, dental, learning disability, psychiatric or counseling treatments arranged on behalf of this child: _________________________________________________________________ _________________________________________________________________ Please list any hobbies or recreational interests enjoyed by this child during the past year: _________________________________________________________________ _________________________________________________________________ Were there any contacts with the child’s parents this past year? Have they visited or attempted to contact the child? What reaction did the child have to the visits or attempted contacts? Do the parents express a willingness and capability of having this child returned to them? Supplementary Local Rules Fourth Judicial District, Circuit Court of the State of Oregon for Multnomah County Draft Revision to be Effective February 1, 2008 American LegalNet, Inc. www.FormsWorkflow.com (14) (15) (16) (17) (18) _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ During the past year I have received $_____________ from _________________ to help support this child. I spent $___________ of that income on behalf of this child and I now have $___________ remaining. I have (___) / have not (___) been convicted of a crime since my last report. I have (___) / have not (___) filed to receive bankruptcy since my last report. I have (___) / have not (___) had my driver’s license suspended or revoked since my last report because of: Please provide any other information you feel should be provided to the Court regarding this child’s adjustment to your care (use the back of this report form if necessary): _________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ Guardian’s Signature:_______________________________ Printed Name:_______________________________ Today’s Date: THIS PERSON’S SIGNATURE WAS SUBSCRIBED AND SWORN BEFORE ME ON THIS _____ DAY OF ____________________, 20_____. (SEAL) Notary Public/Deputy Clerk of the Court Commission expires:______________________ (Annual Guardian’s Report/minors-4/2002) (See SLR 9.075(4)) Supplementary Local Rules Fourth Judicial District, Circuit Court of the State of Oregon for Multnomah County Draft Revision to be Effective February 1, 2008 American LegalNet, Inc. www.FormsWorkflow.com