Fillable ANNUAL REPORT OF GUARDIAN OF DISABLED PERSON In (Montgomery County Maryland)

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ANNUAL REPORT OF GUARDIAN OF DISABLED PERSON In (Montgomery County Maryland)

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In the Matter of
ANNUAL REPORT OF GUARDIAN OF DISABLED PERSON
(Md. Rule 10-206(e))
NOTE: Guardians of the person of disabled persons 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.”
Disabled person’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 disabled person
A. RESIDENCE AND HOUSING
Disabled person’s address (where he or she lives or is physically present):
Select all that apply:
☐ This is the disabled person’s permanent residence.
☐ This is not the disabled person’s permanent residence. His/Her permanent
residence is located at , .
☐ This is a new address (check if the disabled person’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
☐ Relative’s home:
☐ Hospital or medical facility:
Type of facility (select one): ☐ nursing home ☐ assisted living
☐ group home ☐ residential treatment facility
☐ other (describe):
☐ School:
CC-GN-013 (Rev. 01/2020) Page 1 of 6
CIRCUIT COURT FOR
City/County
, MARYLAND
Located at
Court Address
Case No.
Name of Disabled Person
Date
Name of Guardian
Name of Guardian 2
Address
City, state, zip
Name of school
Name of hospital or facility
Name of relative
Relationship to disabled person
Address
City, state, zip
Docket Reference
Do you plan to change the place where the disabled person lives? ☐ Yes* ☐ No
If yes, explain why:
*You may need permission from the court before you move the disabled person from one
location to another (Estates & Trusts, Art., § 13-708).
B. MEDICAL AND PERSONAL CARE
Conditions. List significant health or mental health issues the disabled person has (asthma,
diabetes, anxiety, etc.):
Issue(s) Treatment/treatment plan
Hospitalizations. Was the disabled person hospitalized during the reporting period? ☐ Yes ☐ No
If yes, explain:
Date Hospital Reason
Providers. Which medical professional(s) did the disabled person see during the reporting period?
Name City, state Date(s) seen
☐ Primary care
☐ Dentist
☐ Eye doctor
☐ Ear doctor
☐ Psychiatrist
☐ Psychologist
☐ Therapist
(mental health)
☐ Physical or
occupational therapist
☐ Speech therapist
☐ Other (describe):
CC-GN-013 (Rev. 01/2020) Page 2 of 6
Medications. List medications the disabled person takes on a regular basis:
Name Purpose Dosage/Schedule
Personal care. Are there problems providing meals, clothing, housing, or transportation for the
disabled person? ☐ Yes ☐ No
If yes, explain:
C. SCHOOL AND JOB TRAINING
School. Does the disabled person 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 disabled person
(in his or her best interest)? ☐ Yes ☐ No (explain):
Job training. Is the disabled person in a job training program? ☐ Yes ☐ No
If yes:
Describe:
D. EMPLOYMENT
Does the disabled person have a job? ☐ Yes ☐ No
If yes:
Type of job:
E. SOCIAL AND RECREATIONAL ACTIVITIES
Describe social or recreational activities the disabled person enjoyed during the reporting period
(sports, hobbies, clubs, adult day care, etc.).
CC-GN-013 (Rev. 01/2020) Page 3 of 6
Name of school City, state, zip
Name of program City, state, zip
Name of employer City, state, zip Hours worked per week
F. CONTACTS
Contact with you. If the disabled person 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 disabled person:
Type Frequency
☐ Telephone
☐ Mail or e-mail
☐ Other (describe):
Contact with others. Describe the disabled person’s contact with family members during the
reporting period.
Visitation plan. Is there a formal visitation plan (guidelines for who visits or communicates with
the disabled person)? ☐ Yes ☐ No
If yes, how is it working?
G. DECISION-MAKING
Describe any changes in the disabled person’s ability to make decisions affecting his or her health.
Is the disabled person involved in decisions about his or her housing, medical care, education,
employment, social or recreational activities, etc.? (select one)
☐ Yes. Describe how:
☐ No. Explain why:
CC-GN-013 (Rev. 01/2020) Page 4 of 6
H. COMMUNITY SUPPORT
List community organizations currently involved with the disabled person (case or care
management, community services, government programs, religious programs, charitable
organizations, etc.).
Organization/Provider Services received City, state
Part II. Information about the guardianship
A. FUNDS
Did the guardian of the property, if any, provide funds toward the disabled person’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):
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):
CC-GN-013 (Rev. 01/2020) Page 5 of 6
D. POWERS OF GUARDIAN(S)
My/Our powers as guardian should (select one):
☐ stay the same.
☐
c
hange in the following ways for the following reasons:
E. O
THER
The court should be aware of the following other matters relating to this guardianship:
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 sinc
e
a
ppointment if this is your first report).
☐
This is a new address since the last report (or sinc
e
a
ppointment if this is your first report).
CC-GN-013 (Rev. 01/2020) Page 6 of 6
Date
Date
Signature of Guardian 1
Printed Name
Address
City, state, zip
Telephone
Signature of Guardian 2 (if applicable)
Printed Name
Address
City, state, zip
Telephone
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ANNUAL REPORT OF GUARDIAN OF DISABLED PERSON In (Montgomery County Maryland)

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Completed 6 May 2021

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