(0/201) Page 1 of 2 STATE OF VERMONT SUPERIOR COURT PROBATE DIVISION Unit Docket No.: In re Guardianship of : ADULT GUARDIANSHIP T he following is a report to the C ourt concerning Name of Respondent for the period beginning and ending . I hereby state under oath that the following facts are true concerning the R espondent who is under my guardianship. 1. R address : Mailing Address Physical Address (if different) Respondent resides in (check one): Private Home Nursing Home Group Home Rehabilitation Facility Other (describe) 2. current health and health care needs: ( describe all aspects of health care for R espondent including his/her physical health, mental health and dental care.) 3. al and employment activities : of Respondent American LegalNet, Inc. www.FormsWorkFlow.com (0/201) Page 2 of 2 4. My activities as guardian for the R espondent : 5. I am am not managing the R ial assets . recent Representative Payee Report you filed with Social Security (Form # SSA - 623 - OCR - SM ). I f you are managing other assets for the Respondent , an annual summary of account must be filed with this report. 6. Recommendations for changes to Guardianship Order: I recommend that the G uardianship O rder be changed: Y es No If Y es, attach a request to modify or amend Guardianship Order. Date Signature of Guardian Signature of Co - Guardian, if any Co - Co - Subscribed and sworn before me on: date My commission expires on: Date of Expiration Signature of Notary American LegalNet, Inc. www.FormsWorkFlow.com