Form Cc 1644 – Fill Out and Use This PDF

Form CC-1644	REPORT OF GUARDIAN FOR AN	Form CC-1644
	INCAPACITATED ADULT

Using This Revisable PDF Form

1. Copies

Original – submitted to the local Department of Social Services.

2.Prepared by guardian.

3.Preparation details

a.If you have any questions about this report, please contact your local office of the department of social services.

b.This report should be completed and submitted to the local department of social services four months after appointment as the guardian and annually thereafter.

OFFICE OF THE EXECUTIVE SECRETARY	SUPREME COURT OF VIRGINIA
	Form CC-1644 Revised 07/13

REPORT OF GUARDIAN FOR AN INCAPACITATED PERSON

COMMONWEALTH OF VIRGINIA

VA. CODE § 64.2-2020

Name of Incapacitated Person:	1
Address of Incapacitated	2
Person:
Circuit Court where Guardian	3			Age:	4
appointed:
Circuit Court Case No.:	5		Date Appointed:	6
Guardian’s Name:		7
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Address:	...................................................................................................................................................................................
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Telephone Number:

10[ ] Initial four-month report [ ] Annual report

The period covered by this report is:	11	to
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12 1. Describe the incapacitated person’s living arrangements:

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2.Describe the current mental, physical and social condition of the incapacitated person (attach additional pages if

13 necessary): ....................................................................................................................................................................................................................

Mental: ...........................................................................................................................................................................................................................

Physical: ........................................................................................................................................................................................................................

Social: .............................................................................................................................................................................................................................

State any changes in the condition of the incapacitated person in the past year:..................................................................................

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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:

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FORM CC-1644 (MASTER, PAGE ONE OF TWO) 07/13

Form CC-1644	REPORT OF GUARDIAN FOR AN	Form CC-1644
	INCAPACITATED ADULT

Data Elements, PAGE ONE

1.The name of the adult who is the subject of this report.

2.The address of person named in Data Element No. 1.

3.The name of the circuit court where the guardian who is completing this report was appointed.

4.Age of person who is the subject of this report.

5.The case number assigned by the circuit court where the guardian was appointed.

6.The date the guardian who is completing this report was appointed to serve as guardian for the person who is the subject of this report.

7.The name, address and telephone number of the person who was appointed guardian for the person who is the subject of this report.

8.The name, address and telephone number of the person who was appointed conservator for the person who is the subject of this annual report.

9.Check this box if the same person was appointed as both guardian and conservator. If checked, the name, address and telephone number need not be repeated.

10.Indicate by checking the applicable box whether this is the initial four month report or an annual report.

11.Insert the date the reporting period began and the date the reporting period ended.

12.Provide information requested.

13.Provide information requested.

OFFICE OF THE EXECUTIVE SECRETARY	SUPREME COURT OF VIRGINIA
	Form CC-1644 Revised 07/13

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):

1

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5.State whether or not you agree with the current treatment or care plan:

2

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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:

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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.:

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I certify that the information contained in this Annual Report is true and correct to the best of my knowledge.

5		6
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DATE		SIGNATURE OF GUARDIAN
	7	DSS Use Only:
Date Received:		Date Reviewed:

___________________________________________________________________________________

REVIEWER’S SIGNATURE AND TITLE

FORM CC-1644 (MASTER, PAGE TWO OF TWO) 7/00

Form CC-1644	REPORT OF GUARDIAN FOR AN	Form CC-1644
	INCAPACITATED ADULT

Data Elements, PAGE 2

1.Provide information requested

2.Provide information requested.

3.Provide information requested.

4.Provide information requested.

5.Date signed by guardian completing this report.

6.Signature of guardian completing this report.

7.For the use of department of social services personnel only.

OFFICE OF THE EXECUTIVE SECRETARY	SUPREME COURT OF VIRGINIA
	Form CC-1644 Revised 07/13