No.______
IN THE MATTER OF IN THE STATUTORY
THE GUARDIANSHIP OF PROBATE COURT NO.TWO
______, OF TARRANTCOUNTY,
AN INCAPACITATED PERSON TEXAS
GUARDIAN OF THE PERSON'S ANNUAL REPORTON THE
CONDITION OF A MINOR INCAPACITATED PERSON
INSTRUCTIONS: Please fill out the report as thoroughly as possible. Place a check mark in the appropriate boxes and give details if necessary. If you are unsure or the information is not available please indicate accordingly. When completed, have this report notarized and return to the Court.
A. Information About Incapacitated Person ("IP")
1. IP’s Name: ______
2. Age: ______Date of Birth: ______
3. Incapacity:
Is the IP’s Minor status his or her only incapacity? Yes No
If “No,” please describe IP’s secondary incapacitation(s):______
______
4. IP's residence is: Guardian's home Group home StateSchool
Other (describe):______
5. Name of Residence (if applicable): ______IP’s Address: ______
______
Phone No. (if any):______
6. List date IP moved to present residence: ______
7. Has IP changed residences within last 12 months? Yes No
If "Yes", state the reason for the move: ______
______
B. Information About Guardian of the Person
1. Guardian’s Name: ______
2. Mailing Address: ______
______
3. E-mail Address: ______
4. Has the Guardian's mailing address changed in the last year? Yes No
5. Has the Guardian’s E-mail address changed in the last year? Yes No
6. Home Phone:______Work Phone: ______Cell:______
7. Relationship to IP: Family ______ Friend No Relation (Relation) (Volunteer)
C. Visitation/Phone Contact
1.IP Does Does Not live with the Guardian.
(If the IP “Does” live with the Guardian, you may skip the rest of section “C.”)
2. List the number of times you personally visited IP during the last 12 months:______
3. List date of your last personal visit to IP: ______
If you have not visited IP frequently, have you had telephone contact?Yes No
4. How often is telephone contact?______
5. List date of last telephone contact?______
6. Who is the main telephone contact?______
D. Information About IP’s Medical Condition
1. During the past year, IP's mental health has:
Remained the same Improved Deteriorated
Describe:______
______
2. During the past year, IP'sphysical health has:
Remained the same Improved Deteriorated
Describe:______
______
3.During the past year, IP has been treated or evaluated by the following:
Physician’s Name:______
Describe:______
Psychiatrist’s or Psychologist’s Name:______
Describe:______
Social or other Case Worker’s Name:______
Describe:______
Dentist’s Name:______
Describe:______
Other Name:______
Describe:______
4. Does IP have a primary doctor? Yes No
Primary Doctor’s Name:______Address:______Phone: ______
5. I believe my IP has the following unmet medical needs:______
______
- What is being done to address these unmet needs?______
______
E. Information About IP’s Social Conditions
1. During the past year, IP engaged in the following activities: (Describe)
Educational
Name of School:______
Address:______
IP’s Current Grade:______
Please give a statement of IP’s progress in school:______
______
Recreational:______
Social:______
Occupational:______
No activities available. Why?:______
IP refuses or is unable to participate. Why?:______
2. Does the IP have a driver’s license? Yes No
If “Yes,” is the IP covered by auto liability insurance? Yes No
3. Has the IP encountered any significant events in the past year which should be brought to the attention of the Court? Yes No
Describe:______
4. What accomplishments, successes, goals, if any, has the IP achieved this year?______
5. I believe my IP has the following unmet social needs:______
______
6. What is being done to address these unmet needs?______
______
F. Information About IP’s Living Conditions
1. I rate my IP's living arrangements as: (check one)
Excellent Average Below Average
If Below Average is marked, please explain:______
______
2. I believe my IP is Content Unhappy with his or her living arrangements.
3. I believe my IP has the following unmet basic needs: ______
______
- What is being done to address these unmet needs?______
______
G. Information About IP’s Assets and Income
1. Does the IP have a Guardianship of the Estate? Yes No
- Is the IP entitled to any court-ordered child support
that has not been received? Yes No
If “Yes,” please explain:______
- List source and amount of any other benefits you receive on IP's behalf:______
4. List any assets of IP, other than personal effects, that you possess and that you have not listed on Guardian of the Estate's Annual Account:______
______
H.Additional Information
1. My powers as Guardian should:
Remain the same
Be decreased as follows: ______
Be increased as follows: ______
I wish to resign. Explain ______
______
3. I believe the Court should be aware of the following additional information that concerns my IP:______In case of an emergency ~
Name, Address & Phone # of a friend or family member who knows how to reach you:
______
**NOTE: Please attach a recent photograph of the IP to this Annual Report**
DECLARATION
Please PRINT your full name, date of birth and address below:
Guardian / Co-Guardian (if applicable)Name: / Name:
Date of Birth: (month/day/yr) / Date of Birth: (month/day/yr)
Address: / Address:
Email Address: / Email Address:
“I/we declare, under penalty of perjury, that the foregoing is true and correct.”
Executed in Tarrant County, State of Texas
SIGNED on the ______day of ______, 2012.
(date) (month)
______
Signature of Declarant /Guardian Signature of Declarant/Co-Guardian, if applicable
______
Printed Name of Declarant/Guardian Printed Name of Declarant/Co-Guardian
REV 11/2012