Full Name of Party Filing Document

Mailing Address (Street or Post Office Box)

City, State and Zip Code

Telephone

Email Address (if any)

IN THE DISTRICT COURT OF THE	 		JUDICIAL DISTRICT OF THE STATE OF IDAHO, IN AND FOR THE COUNTY OF	

IN THE MATTER OF THE GUARDIANSHIP OF

An adult.		Case No.		

Guardian’s Annual Status Report for an Adult

Fee Category: G4 $ 	

Instructions.
The purpose of this report is to give the court as complete a picture as possible of the status of guardianship for an adult. Do NOT complete this form for a minor who has a guardian.
1.	Your reports are due as follows:
a.	The first report, called a status report, is due within 30 days after the anniversary date of the guardian’s appointment;
b.	A status report is due every year thereafter;
c.	If you resign or are removed;
d.	When the guardianship is terminated unless the court determines that there is no need.
2.	Please answer all applicable questions thoroughly. If the question is not applicable, write N/A.
3.	Do not leave any blanks.
4.	Type or write your answers with black ink and make sure they are readable.
5.	The guardian filling out this report must sign the report under penalty of perjury and file with the court.
6.	The guardian filling out this report must provide copies to the person under guardianship’s attorney and any other individuals specified by the court.
7.	Keep a copy for your records.

Reporting Period.
Is this your first annual report?
 Yes	 No
If Yes, this report covers the dates beginning on the date you were appointed and ending 12 months after the date you were appointed.

If this is not your first annual report.
This report covers the dates beginning  	 (ending date of last report) and ending  	(12 months after last report).
Is this the final report?
 Yes	 No
SECTION 1 – Contact Information.
Person under guardianship’s information.
Person under guardianship’s physical address:  
 
Person under guardianship’s telephone number(s):
Residence: 	Cell: 
Work number:		Email: 
Facility Information or Caregiver information
Name of facility or caregiver: 

If the person under guardianship resides in a facility, please provide a contact person’s name:

Facility or caregiver’s physical address:	

Facility or caregiver’s telephone number(s):
Cell: 		Work number: 	 Fax: 		Email: 	
SECTION 2: Residential Questions: 
Type of residence:
	Residential assisted living home
	Intermediate care facility
	Nursing home
	Home
	Certified family home
	Other (please explain): 				 

Do you have any concerns on the quality of care received by the person under guardianship in the following areas:
Cleanliness	 Yes	 No
Nutrition/Meals	 Yes	 No	
Personal care	 Yes	 No
Privacy	 Yes	 No
Individualized care plans	 Yes	 No
Residential Safety	 Yes	 No
Community safety	 Yes	 No
If you marked Yes to any of the above, please explain: 	

Describe any restrictions placed upon the person under guardianship, such as limiting visitors or phone calls:  	

	
Who imposed the restrictions and when?  	
	
What are the reasons for the restrictions? 	

Describe why this residence was chosen for the person under guardianship: 	

	
Describe the person under guardianship’s satisfaction with where they live: 	

	
Do you believe the person under guardianship could live and function more independently in a different type of setting?	 Yes	 No
Please explain: 	

If Yes, have you tried to change the person under guardianship’s residence?	 Yes	 No
If Yes, was the change a success? If No, why not? 		

Has the person under guardianship’s residence changed in the last 12 months?
 Yes	 No
Please explain why the residence changed: 	

	

Will the person under guardianship’s residence change in the next 12 months?
 Yes	 No	 Unknown	
If Yes or Unknown, please explain: 	

If the person under guardianship lives in a facility, such as a residential assisted living home, an intermediate care facility, a nursing home or other home with more than three non-related residents DO NOT complete the rest of this section; instead move to Section 3.
List other people living in the person under guardianship’s home and their relationship to the person under guardianship: 	

List anyone who moved into the person under guardianship’s home during the last 12 months: 	

List any resident in the person under guardianship’s home paid to provide any services for the person under guardianship. Please list the services provided, amount paid monthly, and the source of payment:
Name: 		
	
Relationship to person under guardianship: 
	
Types of services: 		
	
Monthly payment: 		
Source of payment: 		
Does the person under guardianship live with a convicted felon?
 Yes	 No	 Unknown

If Yes, please explain: 	

SECTION 3 - Person Under Guardianship’s Health.
Please describe the person under guardianship’s current physical health:  
	 Poor	 Fair	 Good		Excellent	
If Poor or Fair, please explain: 	
	
Please describe the person under guardianship’s current mental health:  
	 Poor	 Fair	 Good		Excellent	
If Poor or Fair, please explain: 	
	
Please describe any changes (improvements or declines) to the person under guardianship’s physical and/or mental health in the last 12 months: 	

	
Please describe any medical and/or mental health treatment the person under guardianship received in the last 12 months: 	

	
SECTION 4 - Person Under Guardianship’s Services and Activities.
If the person under guardianship is receiving services of any kind, please list providers: 	

	
Is the person under guardianship involved in selecting which care and services he/she receives?
	 Yes	 No
If No, please explain: 	

Is the person under guardianship involved in developing his/her own care or service plan?
	 Yes	 No 
If No, why not? 	

Comment on the person under guardianship’s ability and desire to participate in social activities, such as local events, worship services, community groups, etc.: 	

	
	
SECTION 5 - Person Under Guardianship’s Financial Status.
Does the person under guardianship have a job?
	 Yes	 No		
If Yes, where: 	
If Yes, explain whether the person under guardianship has control of these wages, and if not, why not: 	

	
Provide a complete description of the person under guardianship’s financial resources under the control of the guardian. If applicable, attach the most recent representative payee accounting provided to the Social Security Administration, or any other required accounting: 	

	
Name and address of conservator, if any: 	
	
Describe efforts to allow the person under guardianship to make decisions regarding finances and any significant changes in the person under guardianship’s ability to manage financial resources: 	

	
SECTION 6 - Guardianship Status.
Describe significant actions taken by you concerning the person under guardianship in the last 12 months: 	

	
How often are you in contact with the person under guardianship and describe the contact?
	
How often have you seen the person under guardianship in person during the reporting period?
	
How often are you in contact with the service providers? 	

Describe any significant problems or unmet needs of the person under guardianship not described elsewhere: 	

	
Would you like an opportunity to discuss changing or terminating the guardianship?
 Yes	 No
If Yes, please explain briefly: 	

Would the person under guardianship like an opportunity to discuss changing or terminating the guardianship?
 Yes	 No
If Yes, please explain briefly: 	

Are you a professional guardian providing guardianship services for a fee and have you rendered these services for three or more persons?
 Yes	 No	
If Yes, please provide a copy of your most recent certification from the Center for Guardianship Certification.

CERTIFICATION UNDER PENALTY OF PERJURY
I certify under penalty of perjury pursuant to the law of the State of Idaho that the foregoing is true and correct.
The undersigned, 	, guardian of
	, the person under guardianship, submits this report as required by Idaho law.

Date Submitted: 					
			Guardian’s Signature

													
			Typed/Printed Name

			Street or Post Office Address

			City, State and Zip Code

Telephone Number(s)

Fax Number

Email

Is this a change in address from your previous report?	 Yes	 No	

CERTIFICATE OF SERVICE

I certify that on (date)  	 , I served a copy of this report to: (name all parties in the case other than yourself)

	Person under guardianship

(Name)

(Street or Post Office Address) 

(City, State, and Zip Code)

	Person under guardianship’s attorney (name and address):

(Name)

(Street or Post Office Address) 

(City, State, and Zip Code)

	Person(s) designated by court order
		(name and address):

(Name)

(Street or Post Office Address) 

(City, State, and Zip Code)
	
	Other(s) (name and address):

(Name)

(Street or Post Office Address) 

(City, State, and Zip Code)	

	By e-mail: 	
 By mail
 By fax (number): 	
 By personal delivery

	By e-mail: 	
 By mail
 By fax (number): 	
 By personal delivery

	By e-mail: 	
 By mail
 By fax (number): 	
 By personal delivery

	By e-mail: 	
 By mail
 By fax (number): 	
 By personal delivery

			
Typed/Printed Name	Guardian’s Signature