INITIAL REPORT OF GUARDIAN - Judiciary of New York

1 INITIAL REPORT OF GUARDIANCOURT OF STATE OF NEW YORKCOUNTY OFin the Matter of the INITIAL REPORT ofAs GUARDIAN forIndex Incapacitated PersonGeneral Instructions1 All guardians must complete Section guardians must attach a copy of the order of you have been appointed GUARDIAN for the personal needs of theincapacitated person, please complete Section you have been appointed GUARDIAN for the property management of theincapacitated person, please complete Section III, the summary andattached schedules pertaining to the guardianship assets and listing property on a schedule, please be specific. For instance-with bank accounts, list name and address of bank, number of accountand balance; with stocks, list number of shares, name of stock, typeand value.

2 (a)If a schedule does not provide enough space, attach additional sheetswith a reference to the schedule to which the information applies.(b)In any schedule, when there is nothing to list, state ''NONE''.(c)Revised 06 IGENERAL INFORMATION(all guardians must complete this section).1 DATE OF THIS :Name:Address (include mailing address, if different):Telephone no.:INCAPACITATED :Address (if a residential facility, include name of director or personresponsible for person's care):State:Zip :Telephone no.:State:Zip :The INITIAL REPORT must be filed no later than ninety (90) days after the issuance ofyour commission as GUARDIAN . File the INITIAL REPORT with the court that appointedyou as GUARDIAN . A copy of the INITIAL REPORT must be sent to the incapacitatedperson by mail, the court evaluator and counsel for the incapacitated person, unlessthe court has ordered otherwise.

3 If the incapacitated person resides in a facility,send a duplicate of the INITIAL REPORT to the chief executive officer of that facility. Ifthe incapacitated person resides in a mental hygiene facility, send a duplicate of theinitial REPORT to the Mental Hygiene Legal Service of the Judicial Department inwhich the residence is located. A copy of the REPORT must also be sent to theexaminer for your county. The name and address of the examiner for your countymay be obtained from County Court or the Appellate Division of State SupremeCourt, Third 06/05-()--()- of orderCourt:Name of Judge/Justice: company name:Bonding company address:Value of bond (If the bonding requirement has been waived, so state):EDUCATIONAL you fulfilled the educational requirements set forth in MentalHygiene Law (a) by completing a training program approved bythe chief administrator?

4 YesNoHave the educational requirements been waived by the court?YesNoIf you have not fulfilled the educational requirements and therequirements have not been waived by the court, please explain:State:Zip :Revised 06 : (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?YesNoIf yes, please provide the date and location of such visits:If no, please explain:TYPE OF you been granted powers over the personal needs of theincapacitated person?YesNoIf yes, please complete Section you been granted powers regarding property management of theincapacitated person?YesNoIf yes, please complete Section 06 IN POWERS:Is there any reason for any alterations in your powers as GUARDIAN asauthorized by the order appointing you?

5 YesNoIf yes, please specify change requested:If you want to change your authorized powers, you must make anapplication within TEN (10) days of filing this REPORT and provide notice to thepersons specified in your order of appointment as entitled to such notice. Ifyou fail to comply with this provision, any person entitled to commence aproceeding under this article may petition the court for a change in the powerson notice to you, the GUARDIAN , and the persons entitled to such notice asstated in the order of NEEDSSECTION IIIf you have been granted powers with respect to personal needs of the incapacitatedperson, please provide the following information, consistent with the order appointingyou:1 Please explain the steps you have taken, consistent with the order appointingyou, to provide for the personal needs of the incapacitated describe the plan for providing for the personal needs of theincapacitated person by setting forth information regarding.

6 Provisions for medical, dental, mental health, or related services:(a)Provisions for any personal and social services:(b)Revised 06/05 Medical, dental and mental health examinations necessary to determinethe health needs of the incapacitated person-(c)Utilization of health and accident insurance and any other private orgovernment benefits to which the incapacitated person may be entitled:(d)Any additional provisions of the plan for providing for the personalneeds of the incapacitated person:(e)Revised 06/05 DATEType of ExaminationDiagnosis/TreatmentPlease indicate whether the incapacitated person has any of the following. Ifso, attach a copy to this (a) living willYesNo(b) health care proxyYesNo(c) surrogate decision-making directiveYesNo(d) any other advance directiveSECTION III PROPERTY MANAGEMENTIf you have been granted powers regarding the property management of theincapacitated person, please provide the following information, consistent with theorder which appointed you, pertaining to the fulfillment of your responsibilities to theincapacitated person to provide for property describe the plan for the management of the property and financialresources of the incapacitated the incapacitated person executed a will?

7 YesNoIf yes, please provide location of complete the following schedules and summary. If you have nothingto list on a schedule, state ''NONE''. 06/05 SCHEDULE APlease provide a complete inventory of the property of the incapacitatedperson over which you have control. List all guardianship assets you had on the firstday of the accounting accounts and cash - please list the name and address of theinstitution, account numbers and balance at the time of yourappointment. Please also list any cash on hand not in bank Value$ and government securities ( , corporate stocks andbonds; Federal, State or municipal bonds and notes).Total Value$Revised 06/05 InstitutionAccount NumberBalancePresent or future interests ( , interests in partnerships, trusts,litigation settlement funds or pensions) - please list and describe allpresent or future interests the incapacitated person has in propertywhich has not been transferred to your control and indicate Value$ personal property ( , furniture, jewelry, artwork) - please listand describe other personal property and indicate estimated Value$TOTAL VALUE OF ALL PERSONAL PROPERTY$Revised 06/05 IIREAL PROPERTY please give the address, description andapproximate value of any real property.

8 Please also provide the dateof filing of statement identifying real property with the County Clerk asrequired by Mental Hygiene Law (a)(6)(vi).TOTAL VALUE OF REAL PROPERTY$SCHEDULE A SUMMARYA ssets on hand at date of property$ property$TOTAL SCHEDULE A$Revised 06/05 AddressDescriptionValueDate of FilingSCHEDULE BPlease provide a complete inventory and identification of all sources of incomethe incapacitated person is entitled to receive, including: interest, dividends, pensionplans, social security benefits, trust income, Please also include any Monthly Income$Revised 06/05 Type of IncomeAmount per monthVERIFICATIONSTATE OF NEW york )SS:COUNTY OF), being duly sworn, state that I am the GUARDIAN of thewithin named incapacitated person and that the attached INITIAL REPORT andschedule(s) contain, to the best of my knowledge and belief, a complete andtrue statement of my activities as such GUARDIAN ; receipts and payments onbehalf of such incapacitated person; money and other property which has comeinto by possession or has been received by other persons by my order orauthority since the date of my appointment; and the value of such property.

9 Ido not know of any error or omission in this REPORT to the prejudice of suchincapacitated (Your name, address and telephone number)Sworn to before me thisdayof20 Notary PublicState:Phone Number:Zip:Revised 06/05-().