REPORT OF GUARDIAN FOR AN INCAPACITATED PERSON COMMONWEALTH OF VIRGINIA VA. CODE � 64.2-2020 Name of Incapacitated Person: Address of Incapacitated Person: Circuit Court where Guardian appointed: Circuit Court Case No.: Age: Date Appointed: ....................................................................................................................................................................................... ....................................................................................................................................................................................... ....................................................................................................................................................................................... Guardian's Name: Address: Telephone Number: Conservator's Name: Address: ....................................................................................................................................................................................... ....................................................................................................................................................................................... ....................................................................................................................................................................................... [ ] Same as Guardian Telephone Number: [ ] Initial four-month report [ ] Annual report The period covered by this report is: 1. ................................................................................. to ........................................................................................ Describe the incapacitated person's living arrangements: .................................................................................................................................................................................................................................................... 2. Describe the current mental, physical and social condition of the incapacitated person (attach additional pages if necessary): Mental: .......................................................................................................................................................................................................................... ................................................................................................................................................................................................................................. .............................................................................................................................................................................................................................. Physical: Social: ................................................................................................................................................................................................................................... State any changes in the condition of the incapacitated person in the past year: .................................................................................................................................................................................................................................................... 3. Describe all medical, educational, vocational and professional services provided to the incapacitated person for the period covered by this report, and state your opinion of the adequacy of the care received by the incapacitated person: .................................................................................................................................................................................................................................................... FORM CC-1644 (MASTER, PAGE ONE OF TWO) 07/13 American LegalNet, Inc. www.FormsWorkFlow.com 4. State the number of times you visited the incapacitated person, the nature of your visits and describe your activities on behalf of the incapacitated person (Guardians are required to visit the incapacitated person as often as necessary to know of his or her capabilities, limitations, needs and opportunities): .................................................................................................................................................................................................................................................... 5. State whether or not you agree with the current treatment or care plan: .................................................................................................................................................................................................................................................... 6. State your recommendation as to the need for continued guardianship, any recommended changes in the scope of the guardianship, and the steps to be taken to make those changes, and any other information useful, in your opinion, to a consideration of the guardianship: .................................................................................................................................................................................................................................................. 7. If you incurred expenses in exercising your duties as guardian and if you requested reimbursement or compensation for those expenses, itemize the expenses and list the person(s) from whom you requested reimbursement or compensation.: .................................................................................................................................................................................................................................................... I certify that the information contained in this Annual Report is true and correct to the best of my knowledge. ..................................................................................... DATE _________________________________________________________________ SIGNATURE OF GUARDIAN DSS Use Only: Date Received: ................................................................................. Date Reviewed: ....................................................................................... ___________________________________________________________________________________ REVIEWER'S SIGNATURE AND TITLE FORM CC-1644 (MASTER, PAGE T