Page 1 GUARDIAN222S REPORT (1/1/18) IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF WASHINGTON Probate Department In the Matter of the Guardianship ) ) of ) No. ) ) GUARDIAN222S REPORT , ) A Protected Person. 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 phone number is: 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: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 GUARDIAN222S REPORT (1/1/18) 5. The person is currently engaged in the following programs and activities and is 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. 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 is None/Describe: 9. The person222s physical condition is as follows (brief description): 10. The person222s mental condition is as follows (brief description): 11. Facts that support the conclusion that the person is incapacitated include the following: American LegalNet, Inc. www.FormsWorkFlow.com Page 3 GUARDIAN222S REPORT (1/1/18) 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: 14. I believe the guardianship should or should not continue because: 15. At the time of my last report, I held the following amount of money on behalf of the person: $. Since my last report, 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: $. 16. 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. 17. Since my last report: (a) I have been convicted of the following crimes (not including traffic infractions): none or describe: (b) I have filed for or received protection from creditors under the Federal Bankruptcy Code. No Yes: Describe (c) I have had a professional or occupational license revoked or suspended. No Yes: Describe: American LegalNet, Inc. www.FormsWorkFlow.com Page 4 GUARDIAN222S REPORT (1/1/18) (d) I have had my driver license revoked or suspended. No Yes: Describe 18. Since my last report, I have delegated the following powers over the protected person for the following periods of time: None / or provide name of person powers delegated to and time: 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 NOTICE: ANY PERSON INTERESTED IN THE AFFAIRS OR WELFARE OF THE PROTECTED PERSON WHO IS THE SUBJECT OF THIS REPORT WHO HAS CONCERNS ABOUT THIS REPORT OR THE GUARDIAN222S PERFORMANCE MAY CONTACT THE COURT AS FOLLOWS: Washington County Circuit Court 150 N. First Avenue Hillsboro, OR 97124 American LegalNet, Inc. www.FormsWorkFlow.com