Initial Guardian Form – Fill Out and Use This PDF

Insert Court Examiner’s Name

INITIAL REPORT OF GUARDIAN

Court OF STATE OF NEW YORK

COUNTY OF

In the Matter of the Initial Report of				,
As Guardian for		,		Index No.
An Incapacitated Person

General Instructions

1.All guardians must complete Section I.

2.All guardians must attach a copy of the Order of appointment.

3.All guardians must sign and file a Designation with, and obtain a Commission from, the county clerk.

4.If you have been appointed guardian for the personal needs of the incapacitated person complete Section II.

5.If you have been appointed guardian for the property management of the incapacitated person complete Section III, the summary and attached schedules pertaining to the guardianship assets and financial resources.

(a)When listing property on a schedule be sure to specify the details. For instance, with bank accounts, list name and address of bank, number of account and balance; with stocks, list number of shares, name of stock, type and value. Do not list any monies held in a Supplemental Needs Trust fund on this report, a separate report is required.

(b)If a schedule does not provide enough space, attach additional sheets with a reference to the schedule to which the information applies.

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(c)In any schedule, when there is nothing to list, state "NONE".

6.All guardians must file an original completed initial report in the county clerk’s office no later than ninety (90) days after the issuance by the county clerk of your commission as guardian.

7.All guardians must send a copy of the initial report to the incapacitated person by mail, unless the court has ordered otherwise.

8.All guardians must send a time-stamped copy of the completed and filed initial report to the Court Examiner assigned to this matter. If you are not aware of the name and address of the Court Examiner, the information may be obtained from the New York State Supreme Court, Appellate Division, Fourth Department at (585)530- 3225.

9.All guardians must send a copy of the completed and filed initial report to any person noted in the Court Order. Also, if the incapacitated person resides in a facility, send a duplicate of your initial report to the chief executive officer of that facility; if the incapacitated person resides in a mental hygiene facility, send a duplicate of your initial report to Mental Hygiene Legal Service at M. Dolores Denman Courthouse 50 East Avenue - Suite 402 Rochester, New York 14604. If you have questions about to whom you need to send a copy of your report, ask the Court Examiner assigned to review your report.

10.If you require additional space to answer any question or portion of a question, attach additional sheets of paper to your report and make a notation within this report form that you are attaching additional sheets of paper.

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SECTION I GENERAL INFORMATION

(all guardians must complete this section).

1.DATE OF THIS REPORT:

2.GUARDIAN(S): (List all guardians who have submitted this report) Name(s):

Address(es) (include mailing address, if different):

Telephone no.:

3.INCAPACITATED PERSON: Name:

Address (if a residential facility, include name of director or person responsible for person's care):

________________________________

________________________________

________________________________

Telephone no.:

Date of Birth:

Last 4 digits of Social Security Number

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4.APPOINTMENT: Date of Order: Court:

Name of Judge/Justice:

Date Designation was signed and filed: (Attach copy of Designation)

Date Commission was issued: (Attach copy of Commission)

5.BOND: (Complete if bond was required by Court Order) Bonding company name:

Date bond was filed:

(Attach copy of Bond)

Bonding company address:

Value of bond:

6.EDUCATIONAL REQUIREMENTS:

Unless waived by the Court, you must fulfill the educational requirements set forth in Mental Hygiene Law § 81.30(a) by completing a training program approved by the chief administrator.

See link for on-line training: http://www.nyCourts.gov/ip/gan/training.shtml.

Have you fulfilled this requirement? Attach certificate.

Yes No

If you have not fulfilled the educational requirements and the requirements have not been waived by the Court explain:

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7.VISITS: (guardians are required to visit the incapacitated person at least four [4] times a year or more frequently as specified by Court Order).

Have you visited the incapacitated person?

Yes No

If yes, provide the date and location of such visits:

Date

Location

1.

2.

3.

4.

5.

6.

If no, explain:

8.TYPE OF GUARDIANSHIP:

Have you been granted powers over the personal needs of the incapacitated person?

Yes No

If yes, complete Section II.

Have you been granted powers regarding property management of the incapacitated person?

Yes No

If yes, complete Section III.

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9.CHANGE IN POWERS:

Is there any reason for any alterations in your powers as guardian as authorized by the Order appointing you?

Yes No

If yes, specify change requested:

If you want to change your authorized powers, you must make an application within TEN (10) days of filing this report and provide notice to the Court Examiner and any other person specified in your Order of appointment as entitled to such notice. If you fail to comply with this provision, any person entitled to commence a proceeding under this article may petition the Court for a change in the powers on notice to you, the guardian, and the persons entitled to such notice as stated in the Order of appointment.

SECTION II PERSONAL NEEDS

If you have been granted powers with respect to personal needs of the incapacitated person, provide the following information, consistent with the Order appointing you:

1.Explain the steps you have taken, consistent with the Order appointing you, to provide for the personal needs of the incapacitated person.

2.Describe the plan for providing for the personal needs of the incapacitated person by setting forth information regarding:

(a)Provisions for medical, dental, mental health, or related services:

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(b)Provisions for any personal and social services:

(c)Medical, dental and mental health examinations necessary to determine the health needs of the incapacitated person:

Date		Type of Examination		Diagnosis/Treatment

(d)Utilization of health and accident insurance and any other private or government benefits to which the incapacitated person may be entitled:

(e)Any additional provisions of the plan for providing for the personal needs of the incapacitated person:

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3.Indicate whether the incapacitated person has any of the following. If so, attach a copy to this report:

(a) living will	Yes				No
(b) health care proxy	Yes				No
(c) surrogate decision-making directive	Yes				No
(d) any other advance directive	Yes				No
(e) MOLST	Yes				No

SECTION III PROPERTY MANAGEMENT

If you have been granted powers regarding the property management of the incapacitated person, provide the following information, consistent with the Order which appointed you, pertaining to the fulfillment of your responsibilities to the incapacitated person to provide for property management.

1.Describe the plan for the management of the property and financial resources of the incapacitated person.

2.Is there a Supplemental Needs Trust?

Yes No

3.Are you required by Court Order to provide an annual report as Trustee of the Supplemental Needs Trust?

Yes No

If yes, provide a copy of the Order establishing the Supplemental Needs Trust to the Court Examiner with this report.

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4.Has the Incapacitated Person executed a will?

Yes No

If yes, provide location of will.

Schedules and Summary follow.

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Complete the following schedules and summary. If you have nothing to list on a schedule, state "NONE".

SCHEDULE A

Provide a complete inventory of the property of the Incapacitated Person over which you have control. List all guardianship assets you had on the first day of the accounting period.

I.PERSONAL PROPERTY

1.Bank accounts and cash - list the name and address of the institution, account numbers and balance at the time of your appointment. Attach a copy of any and all statements indicating a monetary balance as of the time of your appointment. Additionally, list any cash on hand not in bank accounts. If a Supplemental Needs Trust exists, do not list any fund monies here. If reporting for the Supplemental Needs Trust fund is required by Court Order, report separately pursuant to the terms of such Court Order. However, if there was a transfer of monies from the Supplemental Needs Trust into the Incapacitated Person’s estate, list those monies here. Those transferred funds are considered income for the Incapacitated Person’s estate.

Institution		Account Number					Balance

Total Value $

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2.Corporate and government securities (e.g., corporate stocks and bonds; Federal, State or municipal bonds and notes).

Total Value

$

3.Present or future interests (e.g., interests in partnerships, trusts, litigation settlement funds or pensions) - list and describe all present or future interests the Incapacitated Person has in property which has not been transferred to your control and indicate estimated value. Provide copies of all Trust documents. Do not list any Supplemental Needs Trust fund monies here. If reporting for the Supplemental Needs Trust fund is required by Court Order, report separately pursuant to the terms of such Court Order. However, if there was a transfer of monies from a Supplemental Needs Trust into the Incapacitated Person’s estate, list those monies here. Those transferred funds are considered income for the Incapacitated Person’s estate.

Total Value

$

4.Other personal property (e.g., furniture, jewelry, artwork) - list and describe other personal property and indicate estimated value.

Total Value

$

TOTAL VALUE OF ALL PERSONAL PROPERTY

$

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II.REAL PROPERTY - give the address, description and approximate value of any real property. Additionally, provide the date of filing of statement identifying real property with the County Clerk as required by Mental Hygiene

Law § 81.20(a)(6)(vi). (Attach to this report a copy of the statement identifying real property.)

Address	Description			Value		Date of filing

TOTAL VALUE OF REAL PROPERTY

$

Indicate on the above list if the Incapacitated Person is residing in any of the listed real property.

	SCHEDULE A SUMMARY
Assets on hand at date of appointment
I.	Personal property	$
II.	Real property	$
TOTAL SCHEDULE A		$

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SCHEDULE B

Provide a complete inventory and identification of all sources of income or periodic payments the Incapacitated Person is entitled to receive, including: interest, dividends, pension plans, social security benefits, trust income (other than a Supplemental Needs Trust) and any rental income.

Type of income or payment		Amount per month

Total Monthly Income/Payment

$

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		VERIFICATION
STATE OF		)
				ss:
COUNTY OF			)

,being duly sworn, state that I am the guardian of the within named Incapacitated Person and that the attached initial report and schedule(s) contain, to the best of my knowledge and belief, a complete and true statement of my activities as such guardian; receipts and payments on behalf of such Incapacitated Person; money and other property which has come into by possession or has been received by other persons by my order or authority since the date of my appointment; and the value of such property. I do not know of any error or omission in this report to the prejudice of such Incapacitated Person.

_________________________________

Guardian

__________________________________

__________________________________

__________________________________

(Your name, address and telephone number)

Sworn to before me this					day
of		, 20 .

Notary Public

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