IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE …

1 Page 1 of 4 annual report OF A guardian (December 29, 2019) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 IN THE CIRCUIT COURT OF THE STATE OF OREGON FOR THE COUNTY OF CLACKAMAS Probate Department In the Matter of the Guardianship of: ) ) Case No. _____ ) ) annual report OF guardian ) Name of Protected Person ) Note on completing form: Please answer each question every year and add additional pages if necessary. Do not leave any questions unanswered and do not duplicate a completed form from prior years.

2 A separate report must be filed for each protected person and all co-guardians must sign the report . I am the guardian for the person named above and make the following report as required by law. 1. My name is (include all guardians): _____ _____ 2. My address, telephone number, and email are (include all guardians): _____ _____ _____ _____ 3. The name, if applicable, and address of the place where the person now resides are: _____ _____ 4. The person is currently residing at the following type of facility or residence: _____ 5.

3 The person is currently engaged in the following programs and activities and receiving the following services (brief description): _____ _____ _____ 6. I was paid for providing the following items of lodging, food, or other services to the person: _____ 7. The name of the person primarily responsible for the care of the person at the person s place of residence is: _____ Page 2 of 4 annual report OF A guardian (December 29, 2019) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 8. The name and address of any hospital or other institution where the person is now admitted on a temporary or permanent basis are: _____ _____ 9.

4 The person s physical condition is as follows (brief description): _____ _____ _____ 10. The person s mental condition is as follows (brief description): _____ _____ _____ 11. Facts that support the conclusion that the person is incapacitated include the following: _____ _____ 12. I made the following contacts with the person during the past year (brief description): _____ _____ 13. I limited the person s association with (Please specifically name any limitations and briefly describe the limitation): _____ _____ _____ 14.

5 I made the following major decisions on behalf of the person during the past year (brief description): _____ _____ _____ 15. I believe the guardianship should or should not continue because: _____ _____ 16. 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: $_____ Page 3 of 4 annual report OF A guardian (December 29, 2019) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 17.

6 A true copy of this report will be given to the person, any conservator for the person, and any other person who has requested notice. Name of Served Person By Personal service or by mail at: Date served/mailed _____ _____ _____ _____ _____ _____ _____ _____ _____ 18. Since my last report : a. I have been convicted of the following crimes (not including traffic infractions): _____ b. I have filed for or received protection from creditors under the Federal Bankruptcy Code: (yes or no): _____ c. I have had a professional or occupational license revoked or suspended (yes or no): _____ d.

7 I have had my driver license revoked or suspended (yes or no): _____ 19. Since my last report , I have delegated the following powers over the protected person for the following periods of time (provide name of person powers delegated to): _____ _____ 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: _____ _____ 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.

8 DATED: _____ _____ SIGNATURE OF CO- guardian FOR COURT USE ONLY APPROVED:_____ Page 4 of 4 annual report OF A guardian (December 29, 2019) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 NOTICE: ANY PERSON INTERESTED IN THE AFFAIRS OR WELFARE OF THE PROTECTED PERSON WHO IS THE SUBJECT OF THIS report WHO HAS CONCERNS ABOUT THIS report OR THE guardian S PERFORMANCE MAY CONTACT THE COURT AS FOLLOWS: Concerns about this report or guardian s/co-guardians performance may be filed in writing (and mailed) to the Clackamas County CIRCUIT COURT at the address listed below.

9 Clackamas County CIRCUIT COURT Attention: Probate Department 807 Main St OREGON City, OR 97045 Unless formally appearing as an objector in this proceeding, written concerns may not automatically cause a hearing to be set. Any COURT action in response to informal concerns will be at the discretion of a probate judge.