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Street Address:
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Telephone Number:
Case No (if known):
Dept No (if known):
Minor's Full Name:
State:
Nevada
County:
Washoe
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Code: 1125
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IN THE FAMILY DIVISION
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OF THE SECOND JUDICIAL DISTRICT COURT OF THE STATE OF NEVADA
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IN AND FOR THE COUNTY OF WASHOE
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In the Matter of
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A Legally Incapacitated Person.
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____________________________/
Case No.
Dept. No.
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ANNUAL REPORT OF GUARDIAN ON CONDITION OF
A LEGALLY INCAPACITATED PERSON
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Enter the
specified
information
to the right
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, am the Guardian of the above-name Ward
(Name of Guardian)
and my annual report is as follows:
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2. The present age of the Ward is
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3. Living arrangement:
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specified
information
to the right
1. I,
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a. The current address of the Ward is:
b. The Ward’s residence is:
own home/apt.
nursing home
Guardian’s home/apt.
hospital or medical facility
relative’s home
group home
(relationship)
c. The Ward has been in the present residence since
(date)
If moved within the past year, state change(s) and reason(s) for change
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-1-
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specified
information
to the right
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average
below average
Explain
e. I believe the Ward is:
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content with the living situation
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I recommend a more suitable living arrangement for the Ward as follows:
unhappy with the living situation
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specified
information
to the right
excellent
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specified
information
to the right
d. I rate the Ward’s living arrangement as:
4. Physical health:
a. The Ward’s current physical condition is:
excellent
good
fair
poor
b. During the past year, the Ward’s physical condition has:
remained about the same
improved – explain
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worsened – explain
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c. List below the names and address of the Ward’s treating physician(s) and dentist,
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giving the date and purpose of the last visit:
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Date
Dr.’s Name and Address
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specified
information
to the right
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Ailment/Treatment
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specified
information
to the right
a. The Ward’s current mental condition is:
excellent
good
fair
poor
b. During the past year, the Ward’s mental condition has
remained about the same
improved – explain
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specified
information
to the right
5. Mental Health:
worsened – explain
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social worker
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6. Social activities/services:
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specified
information
to the right
c. During the past year, treatment or evaluation by a psychiatrist, psychologist, or
was
was not provided.
a. The Ward’s current social condition is:
excellent
good
fair
poor
b. During the past year, the Ward’s social condition has:
remained about the same
improved – explain
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c. During the past year, the Ward has participated in the following activites:
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recreational
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educational
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social
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occupational
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no activities available
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the Ward refused to participate in any activites
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the Ward was unable to participate in any activities
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7. List of visits:
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specified
information
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a. During the past year, I visited the Ward as follows:
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b. The average amount of time I spent on each visit was:
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c. The last time I visited with the Ward was on
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specified
information
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9. I believe the Ward has the following unmet needs:
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specified
information
to the right
During the past year, I performed the following activities on behalf of the Ward:
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specified
information
to the right
(Date)
8. Activities:
10. The Guardianship
should
should not be continued because:
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11. I
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do not have possession or control of the adult’s estate. If yes, my
accounting is attached.
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//
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//
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do
____________________________________
Date
Signature
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Address
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City, State and Zip
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Phone
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Under penalties of perjury, the undersigned declares that he is the Guardian named in
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the foregoing Account of Guardian and knows the contents thereof; that the document is
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true of his own knowledge except as those matters stated upon information and belief, and
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that as to such matters, he believes it to be true.
___________________________________
Guardian
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SUBSCRIBED and SWORN to before me
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this _________ date of _______________, _______.
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__________________________________________
NOTARY PUBLIC
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