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BASTROP COUNTY COURT REPORTONTHECONDITIONANDWELLBEINGOFWARD IntheGuardianshipof COUNTYCOURT anIncapacitatedPerson BASTROPCOUNTY,TEXAS (Texas Secretary of State)

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BASTROP COUNTY COURT
REPORTONTHECONDITIONANDWELL‐BEINGOFWARD
Page 1 of 8 Updated 2/1/2017
CauseNo.____________________
IntheGuardianshipof§ COUNTYCOURT
§
____________________________, §
anIncapacitatedPerson§ BASTROPCOUNTY,TEXAS
[]INITIAL[]ANNUAL[]FINAL
(checkone)[]GuardianofPerson[]GuardianofPersonandEstate
Completethisform,answeringeveryquestion,exceptwhendirectedotherwise.“Not
Applicable”isnotaproperresponse.ThisformmustbesignedinthepresenceofaNOTARY.
Onthisday,theundersigned,Guardianinthismatter,personallyappearedbeforeme
andafterbeingdulysworn,statedthefollowing:
1. Ward’sName:___________________________________Dateofbirth:___________
Address(noP.O.Box):________________________________________________
City/State/Zip:________________________________________________________
TelephoneNumber:___________________________________________________
2. GuardianCo‐Guardian(ifapplicable)
Name:___________________________________ ______________________________
DateofBirth:_____________________________ ______________________________
PhysicalAddress:_________________________ ______________________________
MailingAddress:__________________________ ______________________________
TelephoneNumber:________________________ ______________________________
RelationshiptoWard:______________________ ______________________________
Duringthepast
reportingyear,haveyoubeenconvictedofafelonyora
misdemeanor,otherthanaminortrafficoffense?
GuardianCo‐Guardian(ifapplicable)
[]Yes[]No [ []Yes[]No
Ifyes,explain
__________________________________________ ______________________________
BASTROP COUNTY COURT
REPORTONTHECONDITIONANDWELL‐BEINGOFWARD
Page 2 of 8 Updated 2/1/2017
3. VisitswithWard:
DuringthepastyearIhavevisitedtheWardinperson______times(ifWardlives
withyou,put365)
Dateoflastvisit:________________________________________.
Iflessthansix(6)visits,pleaseexplain:
______________________________________________________________________________
______________________________________________________________________________
4. WheredoestheWardLive?[]Guardian’sHome[]Ward’sHome
[]Relative’sHome(giverelative’sname):________________________________________________
[]Otherfacility(type)____________________(name)________________________________
HowlonghasWardresidedatpresentresidence?__________________________
HasWard’sresidencechangewithinthepastyear?[]Yes[]No
Ifyes,explain:__________________________________________________________

5. Ward’sIncome:YouMUSTreportthesourceandamountofalltheWard’s
income,regardlessofwhethertheincomeisreceivedbytheWard,
theGuardian,
ortheWard’sfacility(SocialSecuritybenefitsareincome,childsupportisnot).
Source1:_________________________Amount1________________Wk/Mo/Yr
Source2__________________________Amount2________________Wk/Mo/Yr
Ifzero,pleaseexplain:___________________________________________________
6. Ward’sEstate:
HastheCourtAppointedaGuardianfor
Ward’sEstate?[]Yes[]No
Ifyes,pleaseprovidethefollowinginformation:
(a) NameandAddressofGuardianoftheEstate:_________________________
__________________________________________________________________
(b) DoyouasGuardianofthePerson,receiveanallowancefromthe
GuardianoftheEstate?[]Yes[]No
IfYes,annualamountreceived:______________________________________
IfNo,pleaseprovidethefollowinginformation:
(a) HastheCourtorderedyoutomanageanyfundsotherthanSocial
SecurityDisability?[]Yes[]No
IFYes,YOUMUSTREPORTonyourmanagementofthosefundson
anincomeandexpensesworksheetandattachittothisreport.
BASTROP COUNTY COURT
REPORTONTHECONDITIONANDWELL‐BEINGOFWARD
Page 3 of 8 Updated 2/1/2017
(b) AreyoutherepresentativepayeeoftheWard’sSocialSecurity
DisabilityorSocialSecurityRetirementBenefits?[]Yes[]No
**IFYes,YOUMUSTattachacopyofthemostrecentRepresentative
PayeeReportorcompleteaPayeeReportForm.
7. Ward’sHealth:
(a) Wardisunderregularphysician’scare?[]Yes[]No
Ifyes,pleaselistnameandaddressofthatphysician:______________________
_____________________________________________________________________
(b) Duringthepastyear,Wardhasbeentreatedorevaluatedbythefollowing
professionals(Asguardian,itisyourDUTYtoknowthisinformationandprovideit
totheCourt,eveniftheWardresidesinaresidentialfacilitywitharrangedservices):
Physician’sName&Office
Address:______________________________________________________________________
Treatmentprovided:____________________________________________________________
Physician’sName&Office
Address:______________________________________________________________________
Treatmentprovided:____________________________________________________________
Dentist’sName&Office
Address:______________________________________________________________________
Treatmentprovided:____________________________________________________________
OtherName&Address:_________________________________________________________
Treatmentprovided:____________________________________________________________

(c) Ward’smentalhealthhas:(checkone)
[]Remainedthesame
[]Improved.Describe_____________________________________________
[]Deteriorated.Describe__________________________________________
(d) Ward’sphysicalhealthhas:(checkone)
[]Remainedthesame
[]Improved.Describe_____________________________________________
[]Deteriorated.Describe__________________________________________
BASTROP COUNTY COURT
REPORTONTHECONDITIONANDWELL‐BEINGOFWARD
Page 4 of 8 Updated 2/1/2017
(e) AsGuardianofthePerson,I[]HAVEFILED[] HAVENOTFILED
foranEmergencyDetentionoftheWard,pursuanttotheTexasHealth&
SafetyCode.IfyouHAVEFILED,pleaselistthenumberoftimes,reasons
anddates:________________________________________________________
8. Ward’sSocialConditions:(checkone)
(a) IbelievetheWard’slivingarrangementsare[]Excellent[]Average
[]Belowaverage;Explain:_________________________________________
(b)Wardhasparticipatedinthefollowingactivities(checkallthatapply)
(Pleasedescribetheactivities,e.g.movies,eatingout,SpecialOlympics,church,etc.)
[]Recreational:_________________________________________________
[]Educational:_________________________________________________
[]Social:_______________________________________________________
[]Occupational:________________________________________________
[]Other:_______________________________________________________
OR
[]Refusesorisunabletoparticipate.
(c) AsGuardian,IbelievethattheWardis:(checkone)
[]Happy/Contentwithlivingsituation
[]Unhappywithlivingsituation.Pleaseexplain:___________________
_____________________________________________________________________________

(d) AsGuardian,IbelievetheWard[]DOES[]DOESNOThaveunmet
needs(needs=food,shelter,medical).
(e) PleaseattachacurrentphotographoftheWard.[]Photoattached
9. GuardianshipDuties:
(a) Bond(chooseone).
[]Iamnotrequiredtopayabondpremium,because
______________________________________________________________.
[]Ihavepaidthebondpremium.Bondamountis________________.
[]IhavepaidacashbondonfilewithCourt.Amount_____________.
(b) IfasuccessorGuardianneededtobeappointed,pleaselistthenames,
addressesandtelephonenumbersofatoneortwopeopleyoubelieve
wouldbeworthycandidatesfortheCourttoconsider
forsuch
appointment.PleasealsoincludetheirrelationshiptotheWard:
BASTROP COUNTY COURT
REPORTONTHECONDITIONANDWELL‐BEINGOFWARD
Page 5 of 8 Updated 2/1/2017
Name:______________________________________Age:________________
Address:_________________________________________________________
TelephoneNumber:_______________________________________________
RelationshiptoWard:______________________________________________
Name:______________________________________Age:________________
Address:_________________________________________________________
TelephoneNumber:_______________________________________________
RelationshiptoWard:______________________________________________
(c) DoyouneedadditionalLettersofGuardianship?[]Yes[]No
Ifyes,pleaseindicatedthenumberofnewLettersneeded:______________
(d) PleasestateanyadditionalinformationconcerningtheWardthatyouwould
liketosharewiththeCourt.
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
10. FinalReports.OnlycompletethissectionisthisisaFinalReport.
a. IamfilingthisFINALREPORTbecause:
[]Iamresigning
[]theWardhasturned18(pleaseattachbirthcertificate)
[]theWardhaddied(pleaseattachadeathcertificate)
[]other,pleaseexplain:___________________________________________
b. Ifyouareresigning,hasasuccessor
guardianbeenidentified?
[]Yes[]No
Ifyes,pleaseprovidethefollowinginformation:
Name:_____________________________DateofBirth:_________
Address:_________________________________________________
_________________________________________________________
Telephone:________________________________________________
RelationshiptoWard:______________________________________
BASTROP COUNTY COURT
REPORTONTHECONDITIONANDWELL‐BEINGOFWARD
Page 6 of 8 Updated 2/1/2017
(pleasedonotsignuntilyouareinthepresenceoftheNotaryPublic)
_____________________________________ _________________
GUARDIAN’SSIGNATURE DATESIGNED
STATEOFTEXAS §
§
COUNTYOF____________ §
BEFOREME,theundersignedauthority,onthisdaypersonallyappeared
___________________________,knowntometobetheGuardianofthePersondescribed
intheforegoingAnnualReport,andwhosenameissubscribedintheforegoingreport,
who,beingbymefirstdulysworn,didonhisorheroathdeposeandstateasfollows:
“Iherebyswear,underpenaltyofperjury,thattheinformationcontainedinthis
reportisaccuratetothebestofmyknowledge.”
SWORNTOANDSUBSCRIBEDBEFOREMEthis______dayof
______________,20____,tocertifywhichwitnessmyhandandsealofoffice.

_____________________________________
NOTARYPUBLIC
(seal) PrintedName:_______________________
CommissionExpires:_________________

BASTROP COUNTY COURT
REPORTONTHECONDITIONANDWELL‐BEINGOFWARD
Page 7 of 8 Updated 2/1/2017
(IfCo‐Guardian,pleasesigninthepresenceofaNotary)
_______________________________________ ________________________
CO‐GUARDIAN’SSIGNATURE DATESIGNED
STATEOFTEXAS §
§
COUNTYOF____________ §
BEFOREME,theundersignedauthority,onthisdaypersonallyappeared
___________________________,knowntometobetheCo‐GuardianofthePerson
describedintheforegoingAnnualReport,andwhosenameissubscribedinthe
foregoingreport,who,beingbymefirstdulysworn,didonhisorheroathdeposeand
stateasfollows:
“Iherebyswear,underpenaltyofperjury,thattheinformationcontainedinthis
reportisaccuratetothebestofmyknowledge.”
SWORNTOANDSUBSCRIBEDBEFOREMEthis______dayof
______________,20____,tocertifywhichwitnessmyhandandsealofoffice.

_____________________________________
NOTARYPUBLIC
(seal) PrintedName:_______________________
CommissionExpires:_________________
Pleasefileyoursignedreportwith:
BastropCountyClerk’sOffice
P.O.Box577
803PineStreet,Room112
Bastrop,Texas78602
BASTROP COUNTY COURT
REPORTONTHECONDITIONANDWELL‐BEINGOFWARD
Page 8 of 8 Updated 2/1/2017
CauseNo.____________________
IntheGuardianshipof § COUNTYCOURTATLAW
§
____________________________, §
anIncapacitatedPerson § BASTROPCOUNTY,TEXAS
ORDERAPPROVINGGUARDIAN’SREPORT
ONTHECONDITIONANDWELL‐BEINGOFWARD
Onthis_________dayof_____________________,20___,theannualreviewof
theguardianshipandtheannualreportoftheguardianintheabovereferencedand
styledcasecameontobeconsidered.TheCourt,havingexaminedsaidreportfinds
that:
1. ThereportcomplieswithTexasProbateCode§743;
2. Thereportcontainsnothingextraordinarythatwouldwarrantan
unscheduledvisitbyanofficeroftheCourt;and
3. ThereportshouldbeapprovedpursuanttoTexasProbateCode§743(e).
ITISTHEREFOREORDERED,ADJUDGEDANDDECREED,that:
1. Theannualreviewandtheguardian’sannualreportarehereby
APPROVED;
2. ThereviewisherebyOrderedrecorded;
3. TheClerkofthisCourtmayrenewLettersofGuardianshipaccordingto
law;
4. Suchlettersshallremainineffectinaccordancewithlaw;and
5. TheLettersofGuardianshipexpireone(1)yearand120daysafterthe
anniversarydateoftheappointmentoftheGuardian,thatdatebeing
______________________________________,20____.
SIGNEDthis________dayof____________________,20____.

_______________________________________
JUDGEPRESIDING
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BASTROP COUNTY COURT REPORTONTHECONDITIONANDWELLBEINGOFWARD IntheGuardianshipof COUNTYCOURT anIncapacitatedPerson BASTROPCOUNTY,TEXAS (Texas Secretary of State)

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Completed 17 July 2020

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