Fillable STATE OF MICHIGAN CASE NO. and JUDGE REPORT (State of Michigan)

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STATE OF MICHIGAN CASE NO. and JUDGE REPORT (State of Michigan)

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STATE OF MICHIGAN
PROBATE COURT
COUNTY
REPORT OF GUARDIAN ON
CONDITION OF INDIVIDUAL WITH
DEVELOPMENTAL DISABILITY
CASE NO. and JUDGE
Court address Court telephone no.
This report should be completed annually by the guardian or more often if directed by the court.
In the matter of
First, middle, and last name of individual with a developmental disability
PCS Code: CDP
TCS Code: RGD
Approved, SCAO
Form PC 663, Rev. 10/20
MCL 330.1631, MCR 5.409(A)
Page 1 of 3
1. I,
Name (type or print)
, am the guardian of the individual named above, and I report
for the period
Date
to
Date
.
2. Present age of the individual:
.
3. The current address and telephone number of the individual are:
Check here if this is a new address
.
4. The individual's present living arrangement is:
own home relative's home
Relationship
hospital or medical center guardian's home
community placement home other:
5. The individual has been in the present residence since
. Descriptions and addresses of
every residence where the individual has lived during this reporting period and the length of stay at each residence are
as follows:
6. I rate the individual's present living arrangements as excellent. average. below average.
Explain if below average
7. I believe the individual is content with the living situation. unhappy with the living situation. I recommend a
more suitable residence as follows:
Describe
8. The individual's mental condition has remained about the same. improved. deteriorated.
Describe the changes
9. The individual's physical health has remained about the same. improved. deteriorated.
Describe the changes
Report of Guardian on Condition of Individual with Developmental Disability (10/20)
Page 2 of 3
Case No.
10. The individual’s social condition has remained about the same. improved. deteriorated.
Describe the changes
11. The individual has received the following services:
medical. educational. vocational. other professional services.
Describe
12. My visits with and activities on behalf of the individual were:
13. I believe the individual has the following needs:
14. I have the following questions concerning the individual or my responsibilities:
15. Other information requested by the court or necessary in the opinion of the guardian is as follows:
16. The guardianship should should not be continued because:
17. As guardian, I have been ordered by the court to file an annual account, which is attached.
18. Comments:
Date
Date
Signature of guardian
Signature of co-guardian (if applicable)
Address
Address
City, state, zip Telephone no.
City, state, zip Telephone no.
Check here if this is a new address Check here if this is a new address
Report of Guardian on Condition of Individual with Developmental Disability (10/20)
Page 3 of 3
Case No.
I am the appointed standby guardian and am willing to continue to serve in the event the guardian dies, becomes unable
to serve, or resigns from the guardianship.
Date
Signature of standby guardian
Address
City, state, zip Telephone no.
Check here if this is a new address
STATEMENT BY STANDBY GUARDIAN
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STATE OF MICHIGAN CASE NO. and JUDGE REPORT (State of Michigan)

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Completed 7 October 2021

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