Fillable Jud Pfc Mpc821 Guardianship Care Plan Report Incapacitated Person Fill (Commonwealth of Massachusetts)

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Jud Pfc Mpc821 Guardianship Care Plan Report Incapacitated Person Fill (Commonwealth of Massachusetts)

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MPC 821 (8/30/19) RPTA, RPT60
ofpage
Commonwealth of Massachusetts
The Trial Court
Probate and Family Court
Docket No.
GUARDIAN'S
CARE PLAN/REPORT
In the Interests of:
Last Name
First Name
Middle Name
Incapacitated Person
Division
INSTRUCTIONS TO GUARDIAN:
Fill this Report out completely, then sign and date on the last page. Attach separate sheets if needed to complete your
response to the numbered questions. File original Report with the Court and serve the Incapacitated Person with a copy in
hand, or by certified mail, return receipt requested. Complete the Certificate of Service at the end of this Report.
(Check one box)
INITIAL 60 DAY CARE PLAN
ANNUAL REPORT
Age of Incapacitated Person Your relationship to Incapacitated Person
Date of Decree of Guardianship:
CURRENT Reporting Period: from
(date)
to
(date)
Describe the Incapacitated Person's current mental, physical, and social condition.
1.
CURRENT CONDITION OF THE INCAPACITATED PERSON
LIVING ARRANGEMENTS
List the name, address, and type of facility where the Incapacitated Person currently resides or stayed or resided during
this reporting period. Include dates indicating when each stay or residence began and ended.
1a.
Dates of Stay or Residency Address
If facility, list name and type of facility
and answer Q1b. below
Do you consider the current living arrangements or habilitation plan and level of care and treatment to be in the best
interests of the Incapacitated Person? Explain why or why not. Include your opinion about the adequacy of care and
services.
1b.
LEVEL OF CARE
very good good adequate poor
click to add
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MPC 821 (8/30/19) RPTA, RPT60
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SERVICES PROVIDED TO THE INCAPACITATED PERSON2.
Describe the medical, educational, vocational and other services provided to the Incapacitated Person during this
reporting period.
CONDITIONS AND SERVICES
ANTIPSYCHOTIC MEDICATION3.
Is the Incapacitated Person taking and/or receiving antipsychotic medication(s)?
Yes No
PROTECTION OF INCAPACITATED PERSON4.
Have any criminal charges or reports of abuse or neglect involving the Incapacitated Person
been filed with a court or agency since the last report?
Yes No
If Yes, please explain:
GUARDIAN'S VISITS AND CONTACT WITH CAREGIVERS5.
Describe the nature and frequency of your visits with the Incapacitated Person, your contact with caregivers and health
care providers, and any other activities you undertook on the Incapacitated Person's behalf during this reporting period.
INCAPACITATED PERSON'S PARTICIPATION IN DECISION-MAKING6.
Describe the extent to which the Incapacitated Person did/did not participate in decision-making about personal and
health care decisions.
7.
Describe the needs of the Incapacitated Person for a continued guardianship. Include any recommended changes and/or
limitations to the guardianship.
RECOMMENDED CHANGES
FUTURE CARE
FUTURE ARRANGEMENTS8.
Describe what residence, services and levels of personal/health care you expect might change for the Incapacitated
Person during the next 18 months, if any.
MPC 821 (8/30/19) RPTA, RPT60
ofpage
Are you a Representative Payee?9a.
Yes No
9b. Do you hold or receive funds belonging to the Incapacitated Person in your role as Guardian other than as a
Representative Payee?
Yes If Yes, answer Question 9c.
No If No, skip to Question 10.
FINANCES
Yes If Yes, skip to Question 10.
No If No, answer Question 9d.
Is there a Conservator appointed?9c.
SUMMARY OF FINANCIAL ACTIVITY DURING REPORTING PERIOD
9d.
Beginning balance of bank accounts (savings, checking, CDs, money market, etc.) $
Plus (+) money received from any source on behalf of the Incapacitated Person (Social
Security, SSI, pension, disability, interest, etc.)
+
Less (-) total fees to care providers -
Less (-) total monies paid to the Incapacitated Person (personal needs, etc.) -
Less (-) total fees paid to the Guardian -
Less (-) any other expenses (housing, insurance, maintenance, etc.) -
ENDING BALANCE OF BANK ACCOUNTS $
It is unlawful for a Guardian to co-mingle personal funds with funds belonging to the Incapacitated Person. All funds of the
Incapacitated Person MUST be maintained separately and accounted for in this Summary of Financial Activity.
You are required to maintain supporting documentation for all receipts and payments. The Court or any interested persons may
request copies of this documentation at any time.
ADD COMMENTS OR CONCERNS THAT YOU HAVE ABOUT THE INCAPACITATED PERSON OR ABOUT THE
GUARDIANSHIP.
10.
Note: If you wish to modify or terminate this Guardianship, you must file a separate Petition with the Court.
VERIFICATION AND ACKNOWLEDGEMENT
I swear or affirm that the statements contained in this Report are accurate and complete, to the best of my knowledge and belief.
Signed under the penalties of perjury
(date)
.
Guardian's Signature Co-Guardian's Signature (if applicable)
Primary Phone #:
(Address)
(Apt, Unit, No. etc.)
(City/Town) (State)
(Zip)
Print Name
Primary Phone #:
(Address)
(Apt, Unit, No. etc.)
(City/Town) (State)
(Zip)
Print Name
E-mail: E-mail:
MPC 821 (8/30/19) RPTA, RPT60
ofpage
CERTIFICATE OF SERVICE
I certify that on
(date)
I provided a copy of this Guardian's Care Plan/Report to the
Incapacitated Person
Signature of Guardian or Attorney for Guardian
BBO No.:
Primary Phone #:
(Address)
(Apt, Unit, No. etc.)
(City/Town) (State)
(Zip)
Print Name
in hand by certified mail, return receipt requested, at the current address as listed
on page 1 of this Report.
or
E-mail:
(Do Not Write Below This Line-For Court Use Only)
Reviewed by: Date:
accepted. No further review needed.
The filed Guardian's Care Plan/Report has been reviewed and
needs the following further judicial review:
Further judicial review completed by:
Probate and Family Court Judge
Date:
Additional orders:
Justice, Assistant-Register, Assistant-Judicial Case Manager, Judicial Designee
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Jud Pfc Mpc821 Guardianship Care Plan Report Incapacitated Person Fill (Commonwealth of Massachusetts)

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Completed 27 July 2020

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