IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF TILLAMOOK In the Matter of the Guardianship of ) ) ) Case No. ) , ) ) Respondent. ) GUARDIAN222S 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 3. The name, if applicable, and the 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: . 6. I was paid for providing the following items of lodging, food or other services to the person: . 7. The name of the person primarily responsible for the care of the person at the person222s place of residence is: . 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. The person222s physical condition is as follows (brief description): . American LegalNet, Inc. www.FormsWorkFlow.com 10. The person222s mental condition is as follows (brief description): . 11. I made the following contacts with the person during the past year (brief description): . 12. I made the following major decisions on behalf of the person during the past year: . 13. I believe the guardianship should or should not continue because: . 14. I received the following amount of money on behalf of the person: $. I spend the following amount of money on behalf of the person: $. I now hold the following amount of money on behalf of the person: $. 15. 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. 16. 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) I have had my driver license revoked or suspended. Yes No 17. Since my last report, I have delegated the following powers over the protected person for the following periods of time (provide name of person and powers): . 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. Dated this day of , 20. Guardian Guardian American LegalNet, Inc. www.FormsWorkFlow.com