CAUSE NO.____________
IN THE MATTER OF d IN THE COUNTY COURT
GUARDIANSHIP OF
d
OF
_________________________
d
Minor/Incapacitated Person
(FORM REVISED 1-18-07)
DATE GUARDIANSHIP WAS GRANTED:______________________________________(REQUIRED)
I, the undersigned, represent that I am the Guardian of the above named ward, and that my Annual Report to
the Court
is as follows:
If ward is deceased, you will need to close the guardianship as follows: Give date of death:
________________; place of death: __________________________. (If you are guardian of the person
only, sign
and send this form to the
file it
with the
you in
filing a Final Accounting.)
2.. Guardian’s Name: _____________________Address:____________________
City:________________________State:__________Zip Code:______________
Day phone: (
)______________________ Evening phone: ( )_____________________
Relationship to Ward: _________
_____________________________________
3.
Ward’s present address:_____________________
_______________________
City:____________________State:__________Zip Code:____________
Phone No: ( )________________________________________________
Date of Birth: ______________________________ Age: ___________________
REASON FOR GUARDIANSHIP:
___ Minor __ Mental Retardation _____ Alzheimer’s Disease______ Senile Dementia
______
Head Injury
_____ V.A. ______Chronic Chemical
Dependency.
Other:_________________________________________________________________________
4. Where does the Ward live? _____State School;_____ at own home; _______ nursing home;
______ Guardian’s home; ____ Foster home; _____ boarding home; _______ hospital/medical
facility; _____ relative’s home
(relationship to ward) _____________________________________ .
If ward is in a state school, nursing home or hospital/medical facility, give name of facility:
_______________________________________________.
5. How long has Ward lived at above? __________. If there has been a change in the past year, give
reason for the change: ____________________________________________________________
______________________________________________________________________________.
6. Date Guardian last saw Ward: ____________ How many times has the Guardian seen the Ward
in the past year?_________________________________________________________________
7.
Annual Income of the Ward: _______________ SSI ____________Gov’t Benefits
____________
Work Earnings _____________________
Does Guardian have possession or control of the Ward’s estate?________
Is there a separate Guardian for the Ward’s estate? ________ yes _______ no
If yes, does Guardian of the Person receive an allowance from Guardian of the
Estate?
Yes________
No _________
8. The guardian’s bond is either _______ a personal surety bond in the amount of_____________;
or ________ a corporate surety bond in the amount of________ AND is on file in this cause’s court
file. If the bond is a corporate surety
bond, it was renewed on _______ and expires on _________.
9. A. During the past year, the Ward’s mental health has : _______ improved _______ deteriorated
____________ remains unchanged.
If there has been a change, please explain:
___________________________________________
______________________________________________________________________________.
B. During the past year, the Ward’s physical health has: ___________ improved
___________ deteriorated
___________ remains unchanged.
If there has been a change, please explain:
____________________________________________
_______________________________________________________________________________.
10.
A. Is Ward under regular physician’s care? ______ yes ______ no.
B. During the past year, the Ward has been treated or evaluated by the following
professionals with date or
type of service reflected:
Physician: _______________________________________________________________________
Date or Type:_____________________________________________________________________
Psychiatrist:______________________________________________________________________
Date or Type:_____________________________________________________________________
Psychologist: ____________________________________________________________________
Date or Type:____________________________________________________________________
Dentist: ________________________________________________________________________
Date or Type:____________________________________________________________________
Social
Worker:____________________________________________________________________
Date or Type:______________________________________________________________
Date
or Type:_____________________________________________________________________
11.
During the past year the Ward has participated in the following activities: Describe:
Recreational
____________________________________________________________________
Social: _________________________________________________________________________
Occupational ____________________________________________________________________
_____________________________________________________________________________ or
No activities available___ Refuses to participate___ Unable to participate ___
(You may continue writing on the back at any
time)
12. The Ward’s living arrangements are: __ Excellent__ Average__ Below-Average. If below
average, please
explain:____________________________________________________________
______________________________________________________________________________.
13.
Ward is _______ content with living situation _________ unhappy with living
situation.
Please explain: __________________________________________________________________.
14.
The Ward’s unmet needs (if any) are:
_________________________________________________
________________________________________________________________________________
15.
If the Ward is a Minor, is the Ward presently attending school? _____ yes ______no.
If yes, please give the name of the school, school’s phone number for possible
verification.
________________________________________________________________________________
Describe the Ward’s progress in school:____ Fair ____ Good ___ Excellent ___
No visible progress
16. The powers authorized
by this guardianship should be: _____ increased
______ decreased
____ unaltered. Please explain if a
change is recommended:
________________________________________________________________________________
17.
Any additional information the Guardian desires to share with the Court:
______________________
_______________________________________________________________________________.
18.
If this Guardianship should be continued, then state why below: if it should not be
continued, contact
your attorney about closing it.
_____________________________________________________________
NOTE TO GUARDIAN: Your next annual Report of the Guardian is past due
on the 60th day after the one-year anniversary of the guardianship. See your Letter of Guardianship for the exact due
date.
OATH OF GUARDIAN
Before me, the undersigned authority, on this the ______ day of __________, 20____, personally
appeared __________________________ who being first duly sworn on oath that the within and foregoing
Report is a true, correct and complete statement
of the present condition, welfare, and well-being of
____________________________________________, a minor/incapacitated person as of this
date:
SIGNED: ______________________________________
Guardian
SWORN TO
AND SUBSCRIBED BEFORE ME, on this ______ day of ___________, 20_____.
___________________________
NOTARY PUBLIC
IN AND FOR THE
STATE OF TEXAS
ORDER
ACCEPTING ANNUAL REPORT OF THE GUARDIAN OF THE PERSON
On _____________________, 20____, came on to be considered the Annual Report of the
Guardian of the Person of ____________________________, WARD. The Court further finds that the
Guardian's Bond filed with this Court is either a _____ personal surety bond or a _______ corporate surety
bond and Orders that it remain in full force and effect. The Court having examined said Report, it is
THEREFORE ORDERED ENTERED AS RECORD. The next annual report is due on the ______ day of
__________, 20______; and, past due 60 (sixty) days after this date. The Letters of Guardianship expire
on the _________ day of _______________,
20_____.
SIGNED this _______ day of __________________, 20____.
__________________________________
Judge, County Court
Taylor County, Texas