IN THE CIRCUIT COURT OF THE STATE OF OREGON
FOR THE COUNTY OF CLACKAMAS
Probate Department
In the Matter of the Guardianship of |
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Case No. P__________________ |
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ANNUAL REPORT OF GUARDIAN |
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FOR PERIOD ENDING: |
(Enter name of Protected Adult or Minor) |
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(End date) |
Birth Date of Protected Person: _______________
(Note on completing form: Please answer each question every year; add additional sheets if necessary. Do not leave any blanks, and do not duplicate completed form from prior years.)
I/we are the guardian(s) for the person named above and make the following report as required by ORS 125.325. (Note: a separate report must be filed for each protected person.)
1.Name(s) of all guardians: (Note: all guardians must sign report.)
_________________________________________
_________________________________________
2.Contact information for each guardian:
Name: ________________________ Phone: _______________ Email: ____________________
Address: ______________________________________________________________________
Name: ________________________ Phone: _______________ Email: ____________________
Address: ______________________________________________________________________
3.The name (if applicable) and address of the place where the protected person now resides is:
______________________________________________________________________________
______________________________________________________________________________
4.The protected person is currently residing at the following type of facility or residence:
______________________________________________________________________________
______________________________________________________________________________
5.The name of the individual primarily responsible for the care of the protected person at the protected person=s place of residence is:
______________________________________________________________________________
PAGE 1 OF 4 - ANNUAL REPORT OF GUARDIAN (Updated June 1, 2010)
6.The name and address of any hospital or other institution where protected person is now admitted or has been admitted (on a temporary or permanent basis) is:
______________________________________________________________________________
______________________________________________________________________________
7.Please describe the protected person’s physical condition:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
8.Please describe the protected person’s mental condition:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
9.Please describe the contacts you made with the protected person during the past year:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
10.Please describe major decisions made on the protected person's behalf during the past year:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
11.The protected person is currently engaged in the following programs and activities and receiving the following services (brief description):
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
12.Since my last report, I have delegated the following powers over the protected person for the following periods of time:
Name of Person: |
__________________________________________________________ |
Powers delegated: |
__________________________________________________________ |
Period(s) of time: |
__________________________________________________________ |
PAGE 2 OF 4 - ANNUAL REPORT OF GUARDIAN (Updated June 1, 2010)
13.I was paid for providing the following items of lodging, food or other services to the protected person: _______________________________________________________________________
______________________________________________________________________________
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Should the guardianship continue? (Circle one) YES NO Describe why, or why not: |
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______________________________________________________________________________ |
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______________________________________________________________________________ |
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______________________________________________________________________________ |
15.At the time of my last report, I held the following amount of money on behalf of the protected person: $__________________
Since my last report, I received the following amount of money on behalf of the person:
$__________________. The source of this money was _________________________________
I spent the following amount of money on behalf of the person: |
$__________________ |
I now hold the following amount of money on behalf of the person: |
$__________________ |
16.I HEREBY CERTIFY THAT SINCE MY LAST REPORT:
A.I have been convicted of the following crimes (not including traffic infractions):
(If none, so state) _________________________________________________________
B.I have filed for or received protection from creditors under the Federal Bankruptcy code: No _______ If Yes, Bankruptcy Case No. and brief explanation:
________________________________________________________________________
C.I have had a professional or occupational license revoked or suspended:
No ___ If Yes, explain: ____________________________________________________
D.I have had my driver=s license revoked or suspended:
No ___ If Yes, explain: ____________________________________________________
I HEREBY CERTIFY THAT A TRUE COPY OF THIS REPORT HAS BEEN GIVEN OR MAILED TO THE PROTECTED PERSON OR MINOR (IF 14 YEARS OF AGE OR OLDER).
I FURTHER CERTIFY THAT A TRUE COPY OF THIS REPORT HAS BEEN GIVEN TO ANY CONSERVATOR FOR THE PERSON AND TO ALL INDIVIDUALS WHO ARE ENTITLED TO NOTICE, OR WHO HAVE REQUESTED NOTICE, AS FOLLOWS:
PERSON |
By Personal Service or by Mail at: |
Date served/mailed |
_______________________________ |
___________________________ |
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_______________________________ |
___________________________ |
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_______________________________ |
___________________________ |
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I hereby declare that the above report is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury.
DATED: __________________ |
__________________________________________________ |
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SIGNATURE OF GUARDIAN |
I hereby declare that the above report is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury.
DATED: __________________ |
__________________________________________________ |
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SIGNATURE OF CO-GUARDIAN |
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APPROVED this _______ day of _________________, 20___.
__________________________________________________
_____Judge of the Circuit Court
_____Probate Coordinator
PAGE 4 OF 4 - ANNUAL REPORT OF GUARDIAN (Updated June 1, 2010)
