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Report On The Condition And Well-Being Of An Adult Ward - Texas
| Report On The Condition And Well-Being Of An Adult Ward Form. This is a Texas form and can be used in Probate Travis Local County . |
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Form revised 05-02-2011 No. C-1-PB- _____ - _______________ In the Guardianship of § § __________________________________, an Incapacitated Person § In Probate Court No. 1 Travis County, Texas GUARDIAN'S INITIAL ANNUAL FINAL REPORT ON THE CONDITION AND WELL-BEING OF A WARD Check one: Guardianship of Person Only Guardianship of Person and Estate Please fill out this form completely, answering every question, except when directed otherwise. "Not applicable" is not a proper response. On this day, the undersigned, known to me to be the Guardian in this matter, personally appeared before me, and after being duly sworn, stated the following: 1. WARD: Name _______________________________________________ Age_____/DOB ___________ Address (no P.O. Box) ______________________________________________________________ City/State/Zip __________________________________________________________________ Phone ___________________________________ 2. GUARDIAN: Name _______________________________________________ Age_____/DOB ___________ Address (no P.O. Box) ______________________________________________________________ City/State/Zip _________________________________________________________________ Phone ___________________________________ Relationship to Ward: ___________________________________________________________ During the past reporting year, have you been convicted of a felony or a misdemeanor other than a minor traffic offense? YES NO If YES, explain __________________________ If this is your final report, answer the questions in box below. If this is not your final report, skip to #4. 3. FINAL REPORTS ONLY I am filing a Final Report because (check one) I am resigning the ward has turned 18 the ward has died other; if "other," please explain: _______________________________________________________________________________ A. If you are resigning, has a successor guardian been identified? YES NO Name _____________________________________________ Age _______ DOB ___________ Address ________________________________________________________________________ City/State/Zip ___________________________________________________________________ Phone _______________________________ B. If because Ward has turned eighteen, attach birth certificate. C. If because the Ward has died, attach death certificate. 4. During the last year, I have visited the Ward in person ______ times. Date of last visit: __________________ * If ward lives with you, put 365. * If zero visits, please explain: _______________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com 5. Ward's residence is (check one): Ward's home Guardian's home Relative's home (give relative's name) _______________________________________________________________________ Or in the type of facility checked below: Nursing Home Group home Hospital/Medical facility State Supported Living Center (State School) Other Please provide NAME of facility: __________________________________________________________ 6. Length of time the Ward has resided in present home: _______________________________________________ Any change in residence in last year? Yes No If YES, explain: _______________________________ ___________________________________________________________________________________________ 7. All guardians must report on the amount and source of the Ward's income, regardless of whether the income comes to someone other than the guardian (such as the Ward's residence). Note that Social Security benefits are considered income, but that child support is not. A. Source of Ward's income: __________________________________________________________________ B. Annual amount of Ward's income: ____________ If zero, explain: __________________________________________________________________________ 8. Has the Court appointed a Guardian for the Ward's estate? Yes No Depending on your answer, please answer the questions in only one of the boxes below: A. If there is NOT a Guardian for the Ward's estate, please answer the following questions and attach additional information as directed: (1) Has a Court Order directed you to manage any funds of the Ward other than Social Security funds? Yes No If YES, you MUST report on your management of those funds by attaching an income and expenses worksheet to this Annual Report. Forms are available on the Court's website or at the Court (1000 Guadalupe Street, Room #217). (2) Are you the representative payee of the Ward's Social Security Disability (SSI) or Social Security Retirement Benefits? Yes No If YES, you MUST attach to this Annual Report either 1. a copy of your most recent Representative Payee Report provided by Social Security OR 2. the Court's Representative Payee Report Form. If you do not receive the form from Social Security, you can get the Court's form on the Court's website or from the Court. OR B. If there IS a Guardian for the Ward's estate, please answer the following two questions: (1) Are you the Guardian for the Ward's estate? Yes No (2) Do you as Guardian of the Person receive an allowance from the Guardian of the Estate? Yes No If YES, annual amount of allowance received _____________________________________ 9. Has the Court approved a formal "Case Management Agreement" for case management services to the Ward? A Case Management Agreement is a signed contract with a professional case manager that has been formally approved by the Court. (This is not the same as a "Care Plan" from a medical provider.) Yes No If YES, you MUST attach an updated copy of the case manager's care plan for the Ward for the Court's approval. American LegalNet, Inc. www.FormsWorkFlow.com 2 of 5 10. Ward IS IS NOT under regular physician's care. 11. During the past year ward has been treated or evaluated by the following professionals. As a guardian, it's your duty to know this information and to provide the information to the Court even if the Ward's residential facility arranges the services. Physician. Name: ______________________________________________________________________ Describe: _______________________________________________________________________________ Psychiatrist. Name: ____________________________________________________________________ Describe: _______________________________________________________________________________ Social Worker or other case worker. Name: _________________________________________________ Describe: ______________________________________________
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