Probate Personal Status Form – Fill Out and Use This PDF

IN THE PROBATE COURT OF HENRY COUNTY

STATE OF GEORGIA

RE:	﴿
__________________________________	﴿	FILE NO.: _______________________
Printed Name of Incapacitated Adult Ward	)
	)	DUE DATE: _____________________
__________________________________	)
	)
Printed Name of Guardian(s)	)	PRESENT AGE: ____________________
		DATE OF BIRTH: ___________________

ADULT PERSONAL STATUS REPORT

The following is a true and complete reporting concerning the above incapacitated adult covering the period from _____________________________, 20___ to _____________________________ , 20___.

1.Describe the adult ward’s living conditions:

______________________________________________________________________________

______________________________________________________________________________

_____________________________________________________________________________

2.The adult ward’s current address is: ________________________________________________

__________________________________________________________________________ and he/she has resided at this address since: _____________________________________________

3.Describe the adult ward’s living situation (check one):

□Personal Care Home

□Ward’s own home

□Nursing Home

□Guardian’s Home

□A home other than the Guardian’s home and their relationship to adult ward______________

□Other _______________________________________________________________________

4.Date you last observed your adult ward: ______________________________________________

5.How often are you able to visit your adult ward?________________________________________

6.How long are your average visits? ___________________________________________________

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Adult Personal Status Report, July 2014 –KCT

__________________________________

FILE NO.: ______________________

Printed Name of Incapacitated Adult Ward

FINANCIAL REPORTING (check all that apply)

□I/We also serve as Conservator (s) for the adult ward. If so, my/our accounting for the current year is:

□Filed simultaneously with this report.

□Was filed earlier on this date: __________________________________________________

□Not due yet, but will be filed on this date: ________________________________________

□Has not been filed yet because: ________________________________________________

OR

□I/We do not serve as Conservator for the adult ward

□I/We have not received funds for the support, care, education, health and welfare of the adult ward.

□I/We have received support: Please list a description of the amount(s) and expenditures of all such funds received during the reporting period:

____________________________________________________________________________

VERIFICATION

The answers to the foregoing questions and the information provided with regard to the adult ward are true and correct to the best of my knowledge and belief and are hereby made under oath.

__________________________________	_______________________________________
Guardian/Conservator Signature	Guardian/Conservator Signature
_____________________________________	___________________________________________
Printed Name of Guardian/Conservator	Printed Name of Guardian/Conservator
Sworn to and subscribed before me	Sworn to and subscribed before me
This_____ day of ______________, 20_____.	This _____ day of ___________________, 20_____.
______________________________________	___________________________________________
Notary Public/Probate Court Clerk	Notary Public / Probate Court Clerk
My commission expires:__________________	My commission expires:_______________________

IF YOU FIND THAT YOU NEED TO SELL THE ADULT WARD’S REAL PROPERTY, VEHICLES, STOCKS AND/OR PERISHABLE PROPERTY, PLEASE CONTACT THE PROBATE COURT, OR YOUR ATTORNEY, FOR INFORMATION REGARDING THE REQUIRED PROCEDURE.

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Adult Personal Status Report, July 2014 –KCT

CONFIRMATION OF COMPLIANCE WITH FILING REQUIREMENT

Based on the foregoing Personal Status Report for Adult Ward, said report is hereby accepted for filing in the Probate Court of Henry County.

This ____ day of ______________________20___.

_______________________________________________

CLERK / DEPUTY CLERK, Henry County Probate Court

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Adult Personal Status Report, July 2014 –KCT