Fillable ANNUAL REPORT OF GUARDIAN OF A MINOR CIRCUIT (Montgomery County Maryland)

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ANNUAL REPORT OF GUARDIAN OF A MINOR CIRCUIT (Montgomery County Maryland)

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☐ CIRCUIT ☐ ORPHANS’ COURT FOR , MARYLAND
In the Matter of
ANNUAL REPORT OF GUARDIAN OF A MINOR
(Md. Rule 10-206(e))
NOTE: Guardians of the person of minors must complete and file this form each year within 60 days of the
anniversary of their appointment, or as the court otherwise directs. Attach additional sheets if needed.
If a section of this form does not apply, write “Not applicable” or “N/A.”
Minor’s Date of Birth:
Gender: ☐ Female ☐ Male
REPORTING PERIOD
I/We, and (if applicable) ,
make this annual report for the period of to .
Part I. Information about the minor
A. RESIDENCE AND HOUSING
Minor’s address (where he or she lives or is physically present):
Select all that apply:
☐ This is the minor’s permanent residence.
☐ This is not the minor’s permanent residence. His/Her permanent residence
is located at , .
☐ This is a new address (check if the minor’s address changed since the last
annual report or since your appointment as guardian if this is your first report).
Explain why the address changed:
Type of housing (select one):
☐ Own home ☐ Guardian 1’s home ☐ Guardian 2’s home
☐ Foster or boarding home ☐ Group home
☐ Relative’s home:
☐ Boarding School:
☐ Hospital or medical facility:
☐ Residential facility:
☐ Other (describe):
CC-GN-014 (Rev. 01/2020) Page 1 of 6
City/County
Located at
Court Address
Case No.
Name of Minor
Date
Date
Name of Guardian
Name of Guardian 2
City, state, zip
Name of school
Name of relative
Relationship to minor
Address
City, state, zip
Name of hospital or facility
Name of facility
Docket Reference
Do you plan to change the place where the minor lives? ☐ Yes ☐ No
If yes, explain why:
B. MEDICAL
AND PERSONAL CARE
Conditions. List significant health or mental health issues the minor has (asthma, diabetes, anxiety,
etc.):
Issue(s)
Treatment/treatment plan
Hosp
italizations. Was the minor hospitalized during the reporting period? ☐ Yes ☐ No
If yes, explain:
Date Hospital Reason
Prov
iders. Which medical professional(s) did the minor see during the reporting period?
Name City, state Date(s) seen
☐ Primary care/pediatrician
☐ Dentist
☐ Eye doctor
☐ Ear doctor
☐ Psychiatrist
☐ Psychologist
☐ Therapist
(mental health)
☐ Physical or occupational
therapist
☐ Speech therapist
☐ Other (describe):
CC-GN-014 (
Rev. 01/2020) Page 2 of 6
Medications. List medications the minor takes on a regular basis:
Name Purpose Dosage/Schedule
Perso
nal care. Are there problems providing meals, clothing, housing, or transportation for the
minor? ☐ Yes ☐ No
If yes, explain:
C. SCHO
OL AND JOB TRAINING
Schoo
l. Does the minor attend school? ☐ Yes ☐ No
If yes:
Is there a care plan or an Individualized Education Program (IEP)? ☐ Yes ☐ No
If yes, did you participate in developing the care plan or IEP? ☐ Yes ☐ No
Do you believe the care plan or IEP is good or appropriate for the minor (in his or
her best interest)? ☐ Yes ☐ No (explain):
Job tr
aining. Is the minor in a job training program? ☐ Yes ☐ No
If yes:
Describe:
D. EMPLOYMENT
Does the minor have a job? ☐
Yes ☐ No
If yes:
Type of job:
E.
SOCIAL AND RECREATIONAL ACTIVITIES
Describe the minor’s social or recreational activities during the reporting period (sports, hobbies,
clubs, etc.):
CC-GN-014 (
Rev. 01/2020) Page 3 of 6
Name of school
City, state, zip
Name of program
City, state, zip
Name of employer
Hours worked per week
City, state, zip
F. CO
NTACTS
Contact with you. If the minor does not live with you, how often did you visit him or her during
the reporting period?
Describe your other types of contact with the minor:
Type Frequency
☐ Telephone
☐ Mail or e-mail
☐ Other (describe):
Contact with others. Describe the minor’s contact with family members during the reporting period:
G. COM
MUNITY SUPPORT
List community organizations currently involved with the minor (case or care management,
community services, government programs, religious programs, charitable organizations, etc.).
Organization Services received
Part II. Information about the guardianship
A. FUNDS
Did the guardian of the property, if any, provide funds toward the minor’s support, care, or
education? ☐ Yes ☐ No ☐ Not applicable
If yes, describe (Select all that apply):
☐ clothing ☐ food ☐ housing ☐ health care (co-pays, insurance, etc.)
☐ transportation ☐ education ☐ extracurricular/recreational activities ☐ job training
☐ other (describe):
CC-GN-014
(Rev. 01/2020) Page 4 of 6
City, state
B. HEALTH OF GUARDIAN(S)
Guardian 1 (select one):
☐ I have no serious health problems that affect my ability to serve as guardian.
☐ I have the following serious health problems that may affect my ability to serve as guardian:
Guardian 2 (if any) (select one):
☐ I have no serious health problems that affect my ability to serve as guardian.
☐ I have the following serious health problems that may affect my ability to serve as guardian:
C. CONTINUATION OF GUARDIANSHIP
This guardianship (select one):
☐ should be continued.
☐ should not be continued for the following reason(s):
D. POWERS OF GUARDIAN(S)
My/Our powers as guardian(s) should (select one):
☐ stay the same.
☐ change in the following ways for the following reasons:
E. OTHER
The court should be aware of the following matters relating to this guardianship:
CC-GN-014 (Rev. 01/2020) Page 5 of 6
I/we solemnly affirm under the penalties of perjury that the contents of this document are true to the best of
my/our knowledge, information, and belief.
☐ This is a new address since the last report (or since
appointment if this is your first report).
☐ This is a new address since the last report (or since
appointment if this is your first report).
CC-GN-014 (Rev. 01/2020) Page 6 of 6
Date
Signature of Guardian 2 (if applicable)
Printed Name
Address
City, state, zip
Telephone
Date
Signature of Guardian 1
Printed Name
Address
City, state, zip
Telephone
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ANNUAL REPORT OF GUARDIAN OF A MINOR CIRCUIT (Montgomery County Maryland)

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Completed 6 May 2021

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