Alaska Form Guardianship – Fill Out and Use This PDF

		IN THE SUPERIOR COURT FOR THE STATE OF ALASKA
					AT____________________
In the Matter of the Protective Proceedings of: )
					)
Name of Ward:					)
							)
Date of Birth:					)
							)
Residential location of ward:					)
							)
					)				CASE NO.
Ward’s Telephone #:					)
								)	GUARDIANSHIP ANNUAL REPORT

Instructions

Please type or print clearly using black ink. In preparing the report, you must consult with the ward as much as possible. The court will treat the information in this report as confidential.

If you are unable to complete this form without help, you may find assistance on the website of the Office of Public Advocacy (OPA): www.state.ak.us/guardianship. Your local library and court may also have a binder of helpful information entitled “Family Guardian Education Materials,” prepared by the Alaska State Association for Guardianship and Advocacy. You may also call OPA at 269-3500 (in Anchorage), 451-5933 (in Fairbanks) or 1-877-957-3500.

After completing this report, you must sign it under oath (or affirmation) in the presence of a notary public or court clerk. See last page.

If you are a full guardian with the powers of a conservator, you must fill out the entire form. If you are a partial guardian and do not have the powers of a conservator (or if a separate conservator has been appointed), you do not need to fill out the financial information in paragraphs 10 through 16. The purpose of this report is to give the court as complete a picture as possible of the ward’s current situation and what has happened in the last 12 months.

		Reporting Period
This report covers the following period: From					To
		Information About Guardian
Guardian’s Name				Daytime Phone
Mailing Address
		(box or street number)	(city)		(state)		(ZIP)

Check here if this mailing address is new. If you change your address, please notify the court.

Page 1 of 13	Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e)
PG-210 (9/08)(cs)	AS 13.26.118, .255, .380(b) & 13.06.100
GUARDIANSHIP ANNUAL REPORT

In what areas do you have the authority to make decisions for the ward?				housing
medical care	school & job training	employment	social & recreational activities

financial management (you control ward’s finances because you have conservator powers)

If you are a private guardian charging fees, is there a court order authorizing payment of fees and establishing an hourly rate and maximum monthly amount as required by Probate Rule 16 and

AS 08.26.110?

Yes

No

I do not charge fees.

If you are a private professional guardian, do you have professional liability insurance?

Yes. (Attach copy of current Declarations page showing liability limits.) No.

If you want the court to change its order, please file form PG-190.

If this is a Public Guardian appointment, is a suitable private guardian available?

No Yes

Information About Ward

1.Housing.

a.Where does the ward live now? Name of facility or place: Address:

	(street address)			(city)	(state)		(ZIP)
	Type of Residence:	nursing home	assisted living home
b.	Has the ward moved in the past year?		Yes	No	If yes, explain:

	No, because:
Page 2 of 13			Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e)
PG-210 (9/08)(cs)			AS 13.26.118, .255, .380(b) & 13.06.100
GUARDIANSHIP ANNUAL REPORT

If yes, explain why:

f.If the ward lives in a nursing home, assisted living home, group home or other

facility,

(1)Is this the least restrictive setting in which services can be provided to the

ward?

Yes

No

(2)Have you participated in developing the facility’s care plan for the ward?

Yes No.

(3)Do you believe the facility’s care plan is a good one for the ward (in the

ward’s best interests)?	Yes	No Explain:

g.Are there any problems with providing meals, clothing, house cleaning or transportation for the ward?

2.Medical Care.

a.Which of the following medical professionals has the ward seen in the past 12

months?

Doctor’s Name

Phone No. Dates Seen

Medical Doctor

Dentist

Eye Doctor

Ear Doctor

Psychologist or

Psychiatrist

Other:

b.Describe any medical problems (physical or mental) the ward has, and describe what is being done or will be done about them:

Page 3 of 13	Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e)
PG-210 (9/08)(cs)	AS 13.26.118, .255, .380(b) & 13.06.100
GUARDIANSHIP ANNUAL REPORT

c.Describe any plans you have to change the care currently being provided for the ward’s medical problems:

d.Have you discussed these medical issues with the ward?

Yes. Explain what the ward wants:

No. Explain why not:

e.Are there any problems providing medical care or treatment for the ward?

g.Did the ward, while the ward still had the capacity to do so, execute a durable power of attorney for health care or some other advance health care directive

under AS 13.52.010 - .395 or another law?

Yes

No. If yes, who is the

agent authorized to make health care decisions for the ward?

3.School and Job Training.

a.Does the ward attend school or any type of job training?

Yes. Describe studies (include name and location of school):

No, because:

b.Is there any type of education or training that would benefit the ward?

c. Have you discussed this with the ward? Yes. Explain what the ward wants:

No. Explain why not:

Page 4 of 13	Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e)
PG-210 (9/08)(cs)	AS 13.26.118, .255, .380(b) & 13.06.100
GUARDIANSHIP ANNUAL REPORT

Change in Annual Expenses Since Previous Reporting Period Explain any difference more than $1000:

13.	Ward’s Assets at the end of this Reporting Period (Date:									)
	(List all assets the ward owns individually or jointly. Attach extra pages if necessary.)
	a.	Cash on hand (not in an account) $
				(amount)				(where located)
		Explain any changes in the last 12 months:
	b.
		Burial Account
		Name of Bank or Institution		Type of			Account		Balance
				Account			Number

Explain any changes in the last 12 months:

c.Alaska Native Corporation Dividend Account

Explain any changes in the last 12 months:

d.List all other bank accounts, certificates of deposit, etc. Attach the most recent bank statement. Attach additional pages if necessary.

	Name of Bank or Institution	Name(s) on	Account	Balance
		Account	Number

Page 8 of 13	Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e)
PG-210 (9/08)(cs)	AS 13.26.118, .255, .380(b) & 13.06.100
GUARDIANSHIP ANNUAL REPORT

Explain any changes in the last 12 months:

e.List all Brokerage Accounts, Stocks, Bonds, and Other Securities. Attach the most recent account statement. Attach additional pages if necessary.

Explain any changes in the last 12 months:

f.Retirement Accounts.

Explain any changes in the last 12 months:

g.Ward’s Life Insurance Policies (policies the ward owns).

Explain any changes in the last 12 months:

h.Real Estate that Ward Owns (land and buildings). Attach tax assessment, if available.

(1)	Does ward own a home?			No	Yes. Estimated Value: $
	Address:
	Description:
	Is there a joint owner?			No	Yes

Explain any changes in the last 12 months:

Page 9 of 13	Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e)
PG-210 (9/08)(cs)	AS 13.26.118, .255, .380(b) & 13.06.100
GUARDIANSHIP ANNUAL REPORT

c. Credit Cards.

Company (Name & Address)		Card		Card Number		Balance Due

Explain any changes in the last 12 months:

d.Judgments/liens.

Description		Balance Due

Explain any changes in the last 12 months:

e.Amounts Owed For Services.

Service

To Whom Owed

Balance Due

(1)Medical Services

(2)Attorney Services

(3)Guardian Services

(4)Other

Explain any changes in the last 12 months:

Page 12 of 13	Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e)
PG-210 (9/08)(cs)	AS 13.26.118, .255, .380(b) & 13.06.100
GUARDIANSHIP ANNUAL REPORT

16.Trusts. The ward is a beneficiary of the following trust(s) (meaning the ward has the right to receive benefits of some kind from the trust):

Name of Trust:

Name and Address of Trustee:
If registered with the court, list trust registration no.				State
Do you know what benefits the ward is supposed to receive from the trust?
Yes	No

Is the ward receiving the benefits from the trust that he/she is supposed to receive?

Yes

No

I do not know.

Explain any changes in the last 12 months:

I do solemnly swear (or affirm) that the information given in this report is true and correct to the best of my knowledge and belief.

Date	Guardian’s Signature
Subscribed and sworn to or affirmed before me at		, Alaska
on ______________________, 20____.

(SEAL)		Clerk of Court, Notary Public or other person
		authorized to administer oaths.
		My commission expires:
I certify that on		, I gave

a copy of this report and its attachments to:

ward

ward’s attorney or guardian ad litem (if currently representing ward): parent or guardian with whom ward resides (if any):

ward’s conservator (if a separate conservator has been appointed): the following person(s) designated by court order:

Guardian’s Signature

Page 13 of 13	Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e)
PG-210 (9/08)(cs)	AS 13.26.118, .255, .380(b) & 13.06.100
GUARDIANSHIP ANNUAL REPORT