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REPORT ON THE CONDITION AND WELL-BEING OF A (Brazos County, Texas)

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BROWSE BRAZOS COUNTY, TEXAS (TX) FORMS

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Updated 4/18/18
No. ____________-G
In the Guardianship of
__________________________________, an Incapacitated Person
§
§
§
In County Court
At Law No. _____
Brazos County, Texas
GUARDIAN’S INITIAL ANNUAL FINAL
REPORT ON THE CONDITION AND WELL-BEING OF A WARD
Annual Report Period: ____________________________
(fill in the dates this report covers)
Check one: Guardianship of Person Only Guardianship of Person and Estate
Please fill out this form completely, answering every question, except when directed otherwise.
“Not applicable” is not a proper response and can delay processing and approval.
On this day, the Guardian in this matter stated the following under penalty of perjury, declaring that each
statement is true and correct:
1. Ward: Name _______________________________________________ Age_____/DOB___________
Address (no P.O. Box)_________________________________________________________
City/State/Zip________________________________________________________________
Phone ___________________________________ New Address? YES NO
Email ___________________________________
Diagnosis/Reason for the Guardianship___________________________________________
2. Information Name _________________________________________ Age ______/DOB ___________
For Address (no P.O. Box) ______________________________________________________
1st Guardian: City/State/Zip _______________________________________________________________
Phone ___________________________________ New Address? YES NO
Email ___________________________________
Relationship to Ward:___________________________________________________________
During the past reporting year, have you been convicted of a felony or a misdemeanor other
than a minor traffic offense? YES NO If YES, explain_____________________
If you are a private professional guardian, a guardianship program, or the Department of
Aging and Disability Services, have you been the subject of an investigation conducted by
the Judicial Branch Certification Commission during the past reporting year? YES NO
Information Name _________________________________________ Age ______/DOB ___________
For Address (no P.O. Box)_________________________________________________________
2nd Guardian: City/State/Zip_________________________________________________________________
(if applicable) Phone ___________________________________ New Address? YES NO
Email ___________________________________
Relationship to Ward:___________________________________________________________
During the past reporting year, have you been convicted of a felony or a misdemeanor other
than a minor traffic offense? YES NO If YES, explain ____________________
If you are a private professional guardian, a guardianship program, or the Department of
Aging and Disability Services, have you been the subject of an investigation conducted by
the Judicial Branch Certification Commission during the past reporting year? YES NO
If co-guardians,
both must be listed.
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If this is your final report, answer the questions in box below. If this is not your final report, skip to #4.
3. FINAL REPORTS ONLY
I am filing a Final Report because (check one)
I am resigning the ward has turned 18 the ward has died
other; if “other,” please explain:
__________________________________________________
A. If you are resigning, has a successor guardian been identified? YES NO
Name _____________________________________________ Age _______ DOB
________________________________________________________________________
Address
________________________________________________________________________
City/State/Zip_____________________________________________________________
Phone: ______________________________________________
B. If because Ward has turned eighteen, attach birth certificate (with social security # deleted).
C. If because the Ward has died, attach death certificate (with social security # deleted).
4. During the last year, I have visited the Ward in person ______ times. Date of last visit:__________________
* If ward lives with you, put 365, and put today’s date as “Date of last visit”
* If zero visits, please explain:_______________________________________________________________5.
Ward’s home
Guardian’s home
Relative’s home (give relative’s name)_______________________________________________________
_
Or in the type of facility checked below:
Nursing Home Group home Hospital/Medical facility
State Supported Living Center (State School) Other
Please provide the name, address and phone number of the facility: ___________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
6. How long has the Ward lived at this address? _________________________________________________
7. All guardians must report on the amount and source of the Ward’s income, regardless of whether the
income comes to someone other than the guardian (such as the Ward’s residence). Note that Social Security
benefits are considered income, but that child support is not.
A. Source of Ward’s income:__________________________________________________________________
B. Annual amount of Ward’s income: _______________ (monthly x 12)
If zero, explain:__________________________________________________________________________
8. In addition to the Guardian of the Person, is there a Court-appointed Guardian of the Ward’s estate?
Yes No Note: just because you are the Rep Payee does not necessarily mean there is a
guardianship of the estate.
Depending on your answer, please answer the questions in only one of the boxes below:
A. If there is NOT a Guardian for the Ward’s estate, please answer the following questions and
attach additional information as directed:
If you
answered
“NO” to
question 8
3 of 6
(1) Has a Court Order directed you to manage any funds of the Ward other than Social Security
funds? Yes No
If YES, you MUST report on your management of those funds by attaching an income
and expenses worksheet to this Annual Report. Forms are available on the Court’s
website at www.brazoscountytx.gov.
(2) Are you the representative payee of the Ward’s Social Security Disability (SSI) or
Social Security Retirement Benefits? Yes No
If YES, you MUST attach to this Annual Report either
1. a copy of your most recent Representative Payee Report provided by Social Security
OR
2. the Court’s Representative Payee Report Form. If you do not receive the form from
Social Security, you can get the form on the Court’s website or from the Court.
OR
B. If there IS a Guardian for the Ward’s estate, please answer the following two questions:
(1) Are you the Guardian for the Ward’s estate? Yes No
If yes, you must file an Annual Accounting in addition to the Annual Report.
(2) Do you as Guardian of the Person receive an allowance from the Guardian of the Estate?
Yes No
If YES, annual amount of allowance received__________________________________
9. Has the Court approved a formal “Case Management Agreement” for case management services to
the Ward? A Case Management Agreement is a signed contract with a professional case manager that has
been formally approved by the Court. (This is not the same as a “Care Plan” from a medical provider.)
Yes No
If YES, you MUST attach an updated copy of the case manager’s care plan for the Ward for the Court’s approval.
10. During the past year ward has been treated or evaluated by the following professionals:
** Note: It is your duty to know this information and provide it to the Court
even if the Ward’s residential facility arranges the services.**
Does the Ward see this doctor on a regular basis? Yes NO
Physician. Name:______________________________________________________________________
Describe:_______________________________________________________________________________
Psychiatrist. Name:____________________________________________________________________
Describe:_______________________________________________________________________________
Social Worker or other case worker. Name:_________________________________________________
Describe:_______________________________________________________________________________
Dentist. Name:________________________________________________________________________
Describe:_______________________________________________________________________________
Other. Name:_________________________________________________________________________
Describe:_______________________________________________________________________________
11. Social Conditions: During the past year the ward has participated in the following activities.
If you
answered
“YES” to
question 8
4 of 6
What does your ward do all day? Note that for each type of activity checked, you must
describe the activities (e.g., movies, bowling, Special Olympics, church, eating out, etc.).
Don’t leave blank or simply write the name of the residential facility.
Recreational:__________________________________________________________________________
Educational:__________________________________________________________________________
Social:_______________________________________________________________________________
Occupational:_________________________________________________________________________
None available.
Refuses or is unable to participate.
12. During the past year the ward’s mental health has:
Remained about the same
Improved. Describe:___________________________________________________________________
Deteriorated. Describe:_________________________________________________________________
13. As Guardian of the Person, I HAVE FILED HAVE NOT FILED for Emergency Detention of the
Ward pursuant to the Texas Health & Safety Code. (An example of emergency detention is a request for an
emergency hospitalization of the Ward for mental health or safety reasons.) If you answered HAVE FILED,
please list the number of times and the dates:
_________________________________________________________________
14. During the past year the ward’s physical health has:
Remained about the same
Improved. Describe:___________________________________________________________________
Deteriorated. Describe:_________________________________________________________________
15. As guardian, I believe the Ward’s living arrangements are Excellent Average Below average
If below average, explain: ________________________________________________________________
______________________________________________________________________________________
16. As guardian, I believe that my ward is
Happy/Content with living situation
Unhappy with living situation
17. As guardian I believe my ward DOES DOES NOT have unmet needs.
(Unmet needs = problems with food, shelter, medical care)
If you answered DOES, please explain:__________________________________________________________
_______________________________________________________________________________________
18. The power authorized by this guardianship should be:
Unchanged
Decreased (explain:____________________________________________________________________)
Increased (explain:____________________________________________________________________)
19. Check each box immediately below to affirm that you already have taken care of the specified duty or that you
will do so within the time indicated. These duties are required by Texas law.
5 of 6
I affirm that I already have done the following or will do so within one week of the date I sign this
Report: I have communicated or will communicate to the ward that (1) I am seeking to continue,
modify, or terminate the guardianship and (2) the ward has the opportunity to appear before the court to
express the ward’s preferences and concerns regarding whether the guardianship should be continued,
modified, or terminated.
I affirm that I will give the ward a copy of this annual report within 30 days of the date I sign the
Report.
I affirm that the attached Bill of Rights has been explained to my ward in his/her native language
or his her/preferred mode of communication in a manner accessible to him/her.
I affirm that I have provided the ward’s spouse, parents, children, and adult siblings, if any,
notification that the relative must elect in writing in order to receive notice of (1) the ward’s death,
(2) admission of the ward to a medical facility for three or more days, (3) change in the ward’s
residence, or (4) the ward’s stay at a location other than his/her residence for a period that exceeds
one calendar week. (You MUST notify the Court if this has not been done or if an exception applies
under Texas Estates Code §1151.056.)
20.
Guardian’s Bond: Check the appropriate box below, adding an explanation if requested.
Note: Even if Ward’s residential facility pays your bond premium for you, it is your
responsibility to verify that the bond payment is current and then mark “have paid.” If
you are not sure, you can look for a statement that the premium was paid on one of the
accountings the facility sends you, or you can call the facility and ask.
I HAVE PAID the bond premium for the next reporting period.
I HAVE NOT PAID the bond premium for the next reporting period (explain:_____________________)
I have a CASH BOND on file with the Court.
DADS guardianship.
21.
If possible, please attach a current photograph of the ward.
22. Please state any additional information concerning the ward that you would like to share with the Court.
(You may continue on another page.)
__________________________________________________________________________________________
__________________________________________________________________________________________
23.
Remember to order fresh “Letters of Guardianship.”
A. To request new letters of guardianship, call (979) 361-4131. Letters are not sent automatically; you
must renew your letters of guardianship annually.
B. Please note two additional things:
(1) There may be fees required by the clerk. You can call the clerk’s call center to verify: (979) 361-
4131.
(2) If there is also a guardianship of the estate, new Letters cannot be issued until the annual account is
approved. (Note that an annual account cannot be approved until your attorney has submitted
everything necessary to the Court, including required back-up.)
Complete the following. The signature below does not require a notary.
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I, _________________________________, the guardian of the person for _____________________________,
(insert name of guardian of the person) (insert name of ward),
in Brazos County Texas, declare under penalty of perjury that the foregoing is true and correct.
Executed on _________________________ 20___________ ___________________________________
Guardian’s signature
If this report is for Co-Guardians, the Co-Guardian must also complete the following:
I, ___________________________________, the guardian of the person for _______________________________,
(insert name of co-guardian of the person) (insert name of ward),
in Brazos County Texas, declare under penalty of perjury that the foregoing is true and correct.
Executed on _________________________ 20___________ ___________________________________
Co-Guardian’s signature (if any)
Mail or deliver to:
Brazos County Clerk’s Office
300 E. 26
th
St., Ste. 1430
Bryan, TX 77803
Or electronically file with the Clerk’s office.
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REPORT ON THE CONDITION AND WELL-BEING OF A (Brazos County, Texas)

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Completed 30 January 2022

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