EXAMINER'S REPORT ON ANNUAL REPORT OF GUARDIAN, …

1 Examiner Name: _____EXAMINER'S REPORTON ANNUAL REPORT OF GUARDIAN, COMMITTEE OR CONSERVATOR* (Mental Hygiene Law )Period of Accounting: _____Name of Incapacitated Person: _____ Index No. _____Reporting guardian of Person and Property: _____Reporting guardian of Person ONLY: _____Reporting guardian of Property ONLY: _____Name of Judge or Justice Appointing guardian : _____Date of Order/Judgment Appointing guardian : _____Date of filing of guardian 's ANNUAL REPORT : _____Date of filing of guardian 's Last ANNUAL REPORT : _____I - the ANNUAL REPORT provide all of the information concerning the incapacitated personrequired by Mental Hygiene Law (b) (1) - (5)? Yes NoIf not, in what respect is the REPORT deficient? the guardian discharged the duty to visit the incapacitated person at least four times a yearas required by Mental Hygiene Law (5) (a)?

2 Yes NoIf not, please explain. * As used in this REPORT , the term " guardian " shall also be deemed to refer to committees or conservatorsappointed prior to April 1, 1993. Rev: 8/201II - PROPERTY MANAGEMENTC omplete this section only if guardian has been granted powers with respect to the extent that the guardian is charged with property management, does the REPORT containan accounting of the property of the incapacitated person as required by Mental Hygiene Law (b) (7)? Yes the following figures from the guardian 's of estate as of last REPORT (Schedule A): received (Schedule B): received (Schedule C): _____Subtotal assets and income (B+C): incurred (Schedule D): paid (Schedule E): _____Subtotal losses and disbursements (D+E): balance of estate (Schedule F).

3 The examiner satisfied that the accounting is accurate and complete and have all items ofincome and disbursement been satisfactorily verified by bank statements, bills, receipts,cancelled checks and the like? Yes NoIf not, please explainRev: 8/202 III - PERSONAL the extent that the guardian is charged with providing for personal needs, does the reportcontain each of the following items required by Mental Hygiene Law (b) (6)? as to whether current residential setting is best suited to the current needs ofthe incapacitated person. Yes of professional medical treatment given to the incapacitated person inpreceding year. Yes for medical, dental and mental health treatment, and related services for comingyear.

4 Yes concerning the social condition of the incapacitated person (see MentalHygiene Law [b] [6] [iv]). Yes NoIf not, in what respects is the REPORT deficient?Rev: 8/203IV - TERMINATION OR ALTERATION OF the REPORT contain any facts indicating the need to terminate the guardian 's appointmentor to alter the guardian 's power? Yes NoIf yes, please the REPORT indicates any reason for a change in powers authorized by the Court, has theguardian made application within 10 days of filing of the REPORT as required by Mental HygieneLaw (e)? Yes No Not ApplicableIf application has not been made, please explain 's compensation is governed by 22 NYCRR (c). Attach request for payment ofreasonable and necessary disbursements. In estates of $5,000 and under, submit a standardstate of disbursements, if any, claimed by examiner: _____Date of this REPORT (your signature)(your name and address) Rev: 8/204