(Copy Receipt) (Clerk's Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In re the Guardianship of: CASE NO. ___________________________ ________________________________ An Incapacitated Person GUARDIAN'S REPORT, ACCOUNTING, AND PROPOSED BUDGET (ANR) If you need more room to answer any item, please attach an additional page. 1. Date of Appointment and Reporting Period: The Guardian was appointed on____________________. This report covers the period from _________________ through ___________________. The closing date for all reports is _______________ (the ending date of the last reporting period) and the Guardian is required to file reports no later than ______________. The Guardian is to file a report every 2. Scope of Guardianship: [Check all boxes that are appropriate.] Full Guardianship of the Person Limited Guardianship of the Person Full Guardianship of the Estate Limited Guardianship of the Estate 12, 24, 36 months. The Incapacitated Person is a beneficiary of a Trust, which was approved by the Court or is subject to court supervision. The Trustee's name, address, and court case number are: _____________________________________________________________________. GUARDIAN'S REPORT, ACCOUNTING AND PROPOSED BUDGET (ANR) - PAGE 1 OF 6 SPO GDN 02.0290 (12/2015) American LegalNet, Inc. www.FormsWorkFlow.com 3. Contact Information for Facility/Home of Incapacitated Person, Guardian and Standby Guardian: Incapacitated Person Full Name Mailing Address City, State & Zip *Telephone Number Email Address Guardian Standby Guardian 4. Interested Parties: [List each person who has filed a Request for Special Notice of Proceedings and those whom the Court has designated to receive copies of reports.] Name Mailing Address Relationship to Incapacitated Person 5. Interested Governmental Agencies: [Check each box that is applicable.] The Incapacitated Person is a veteran who has served in the United States Military. Notice must be provided to: The Department of Veteran Affairs, Henry M. Jackson Federal Building, 915 Second Avenue, Seattle, WA 98174. 6. Benefits Received. The Guardian receives the following benefits on behalf of the Incapacitated Person: Copes; TANF; SSDI/SSA; HUD; VA; SSI; Medicaid; GAU; Medicare; Food Stamps; CSA; Public Assistance; Other--Specify: __________________________ ____________________________________________________________________________ GUARDIAN'S REPORT, ACCOUNTING AND PROPOSED BUDGET (ANR) - PAGE 2 OF 6 SPO GDN 02.0290 (12/2015) American LegalNet, Inc. www.FormsWorkFlow.com 7. Inventory. An inventory of all property of the Incapacitated Person's estate at the commencement of the Guardianship inventory is contained in this Report. is, or is not on file herein. An updated 8. Periodic Personal Care Plan. [To be filled out by all Guardians of the Person.] a. Status. The Incapacitated Person is now ___________ years of age. The Guardian believes that the Incapacitated Person OR is receiving satisfactory care the Guardian has the following concerns for which a change is requested_________________________________________________________________. b. Change in Residence. The following changes in residence of the Incapacitated Person occurred during the report period:__________________________________________ _____________________________________________________________________. c. Medical Condition. The physical and medical condition of the Incapacitated Person are as follows: _____________________________________________________________ _______________________________________________________________________ _______________________________________________________________________. d. Mental Condition. The mental and emotional condition of the Incapacitated Person are: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________. e. Description of Incapacitated Person's Functional Ability. Following is a description of the functional abilities of the Incapacitated Person: ___________________________ _______________________________________________________________________ _______________________________________________________________________. f. Activities of the Guardian Taken on Behalf of the Incapacitated Person. The following is a description of the activities in which the Guardian has engaged for the benefit of the Incapacitated Person: __________________________________________ _______________________________________________________________________ _______________________________________________________________________. GUARDIAN'S REPORT, ACCOUNTING AND PROPOSED BUDGET (ANR) - PAGE 3 OF 6 SPO GDN 02.0290 (12/2015) American LegalNet, Inc. www.FormsWorkFlow.com g. Description of Recommended Changes in Scope of Authority of Guardian. The scope of authority of the Guardian remains the same, OR should be changed as follows: _______________________________________________________________________ _______________________________________________________________________. h. Names of Professionals Who Have Aided the Incapacitated Person. The following professionals have assisted the Incapacitated Person during the period covered by this report:_________________________________________________________________ ______________________________________________________________________. i. Guardian's Plan for Future Care. The Guardian's care plan, remains the same, OR is changed as follows:__________________________________________________ ______________________________________________________________________ ______________________________________________________________________ _______________________________________________________________________. 9. Proposed Monthly Budget: The Guardian of the Estate/Trustee seeks authority to make expenditures for the Incapacitated Person or beneficiary according to the below monthly budget for the next annual accounting period from _____________ through _____________ : Room and Board Medical Rent/Mortgage Personal and Incidental Expenses Food and Household Expenses Utilities Guardian Fees Attorney Fees Other Total Monthly Expenditures $ $ $ $ $ $ $ $ $ $ 10. Security for Estate Assets: a. Guardian/Trustee's Bond: The Court now requires a bond in the amount of: $ $ b. Total balance in blocked accounts at end of review period: GUARDIAN'S REPORT, ACCOUNTING AND PROPOSED BUDGET (ANR)