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SUPERIOR COURT OF WASHINGTON IN AND FOR SNOHOMISH COUNTY CASE NO. In the Guardianship of: PERIODIC STATUS REPORT PER RCW 11.92.043(2) GR 5 7-03 an Incapacitated Person. I, Guardian of the above reports for the peri od: From: Date (mm/dd/yyyy): To : Date (mm/dd/yyyy): as follows: NOTE: Please attach any furt her information or comments to this form if blanks provided are insufficient. (a) Name of incapacitated person(IP): Present address of IP: Telephone: ( ) That location is: Na me (Check one) licensed care facility with guardian with relative alone other Residential changes during reporting period: S:\Web Forms\)-1.5( Superior Court\)-1.5(pdf\GrdnStatusRpt.doc R RU: 07/01/2003 1 of 3 <<<<<<<<<********>>>>>>>>>>>>> 2(b) Services or programs IP received: (c) Medical status of IP: (d) Mental status of IP: (e) Changes in functional abilities of I.P.: (f) Activities of guardian for the period: (g) Any recommended changes in the scope of the authority of guardian: S:\Web Forms\)-1.5( Superior Court\)-1.5(pdf\GrdnStatusRpt.doc R RU: 07/01/2003 2 of 3 <<<<<<<<<********>>>>>>>>>>>>> 3(h) Name(s) and designations of any professionals who have assisted the IP during the Period: Name: Designation: Name: Designation: Name: Designation: (i) Present address of guardian: Address: City, State, Zip: Phone: Work ( ) Phone: Home ( ) I hereby declare under penalty of perjury of the law osf the State of Washington that the foregoing is true and correct to the best of my knowledge and belief: Signed at , Washington Dated (mm/dd/yyyy): GUARDIAN: (Sig nature) S:\Web Forms\)-1.5( Superior Court\)-1.5(pdf\GrdnStatusRpt.doc R RU: 07/01/2003 3 of 3