The Alaska Guardianship form is a legal document used to report on the well-being and circumstances of a ward under guardianship. This form requires guardians to provide detailed information about the ward's living situation, medical care, education, and social activities, ensuring that the court has a comprehensive understanding of the ward's needs and progress. To begin the process of filling out this important form, click the button below.
The Alaska Guardianship form is a vital document designed to ensure the well-being and protection of individuals deemed unable to manage their own affairs. This form serves as a comprehensive annual report that guardians must complete, detailing the current status and needs of the ward. It includes essential information such as the ward's name, date of birth, and residential location, as well as the guardian's contact details. The form requires guardians to reflect on their decision-making authority in various areas, including housing, medical care, education, and finances. Additionally, it prompts guardians to assess any changes in the ward's living situation or medical needs over the past year. Confidentiality is a priority; therefore, the information provided is treated with the utmost care by the court. Guardians are encouraged to consult with the ward during the preparation of this report to ensure their voice is heard. The completion of this form not only fulfills a legal obligation but also supports the ongoing assessment of the ward's circumstances, promoting their best interests and welfare.
IN THE SUPERIOR COURT FOR THE STATE OF ALASKA
AT____________________
In the Matter of the Protective Proceedings of: )
)
Name of Ward:
Date of Birth:
Residential location of ward:
CASE NO.
Ward’s Telephone #:
GUARDIANSHIP ANNUAL REPORT
Instructions
Please type or print clearly using black ink. In preparing the report, you must consult with the ward as much as possible. The court will treat the information in this report as confidential.
If you are unable to complete this form without help, you may find assistance on the website of the Office of Public Advocacy (OPA): www.state.ak.us/guardianship. Your local library and court may also have a binder of helpful information entitled “Family Guardian Education Materials,” prepared by the Alaska State Association for Guardianship and Advocacy. You may also call OPA at 269-3500 (in Anchorage), 451-5933 (in Fairbanks) or 1-877-957-3500.
After completing this report, you must sign it under oath (or affirmation) in the presence of a notary public or court clerk. See last page.
If you are a full guardian with the powers of a conservator, you must fill out the entire form. If you are a partial guardian and do not have the powers of a conservator (or if a separate conservator has been appointed), you do not need to fill out the financial information in paragraphs 10 through 16. The purpose of this report is to give the court as complete a picture as possible of the ward’s current situation and what has happened in the last 12 months.
Reporting Period
This report covers the following period: From
To
Information About Guardian
Guardian’s Name
Daytime Phone
Mailing Address
(box or street number)
(city)
(state)
(ZIP)
Check here if this mailing address is new. If you change your address, please notify the court.
Residence Address
(street address)
Do you live with the ward?
Yes
Relationship to ward:
(city) (state)
No
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Probate Rule 16(e)(1)(B), 16(e)(3) & 17(e)
PG-210 (9/08)(cs)
AS 13.26.118, .255, .380(b) & 13.06.100
In what areas do you have the authority to make decisions for the ward?
housing
medical care
school & job training
employment
social & recreational activities
financial management (you control ward’s finances because you have conservator powers)
Has a separate conservator been appointed for the ward?
Yes Name:
If you are a private guardian charging fees, is there a court order authorizing payment of fees and establishing an hourly rate and maximum monthly amount as required by Probate Rule 16 and
AS 08.26.110?
I do not charge fees.
If you are a private professional guardian, do you have professional liability insurance?
Yes. (Attach copy of current Declarations page showing liability limits.) No.
Changes in Guardianship Needed
Is there a current need for change in the guardianship?
If yes, explain:
If you want the court to change its order, please file form PG-190.
If this is a Public Guardian appointment, is a suitable private guardian available?
No Yes
Information About Ward
1.Housing.
a.Where does the ward live now? Name of facility or place: Address:
Type of Residence:
nursing home
assisted living home
b.
Has the ward moved in the past year?
c.
If the ward lives in your home, do you charge the ward rent?
If you live in the ward’s home, are you paying rent?
d.Have you discussed the ward’s housing arrangement with the ward?
Yes. Explain what the ward wants:
No, because:
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e.Do you plan to change the place where the ward lives?
Yes, to
If yes, explain why:
f.If the ward lives in a nursing home, assisted living home, group home or other
facility,
(1)Is this the least restrictive setting in which services can be provided to the
ward?
(2)Have you participated in developing the facility’s care plan for the ward?
Yes No.
(3)Do you believe the facility’s care plan is a good one for the ward (in the
ward’s best interests)?
No Explain:
g.Are there any problems with providing meals, clothing, house cleaning or transportation for the ward?
2.Medical Care.
a.Which of the following medical professionals has the ward seen in the past 12
months?
Doctor’s Name
Phone No. Dates Seen
Medical Doctor
Dentist
Eye Doctor
Ear Doctor
Psychologist or
Psychiatrist
Other:
b.Describe any medical problems (physical or mental) the ward has, and describe what is being done or will be done about them:
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c.Describe any plans you have to change the care currently being provided for the ward’s medical problems:
d.Have you discussed these medical issues with the ward?
No. Explain why not:
e.Are there any problems providing medical care or treatment for the ward?
f.Is a no-code (Do Not Resuscitate) provision in place for the ward?
g.Did the ward, while the ward still had the capacity to do so, execute a durable power of attorney for health care or some other advance health care directive
under AS 13.52.010 - .395 or another law?
No. If yes, who is the
agent authorized to make health care decisions for the ward?
3.School and Job Training.
a.Does the ward attend school or any type of job training?
Yes. Describe studies (include name and location of school):
b.Is there any type of education or training that would benefit the ward?
c. Have you discussed this with the ward? Yes. Explain what the ward wants:
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4.Work.
a. Is the ward employed?
Yes. Describe (include type of work, name of employer, address, phone, and how long employed):
b.If not employed, would it be in the ward’s best interests to obtain employment?
5.Social and Recreational Activities.
a.Describe activities the ward enjoys:
b.Have you been able to help make these activities available to the ward?
c.Do you have any plans concerning additional social and recreational activities for the ward?
6.Contacts With Ward.
a.If the ward does not live with you, how often have you visited the ward in the past 12 months?
Have there been any other contacts?
Yes, as follows:
Type of Contact
Frequency of Contact
by telephone
by mail or e-mail through 3rd person: other:
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7.Decision Making.
a.Have there been any changes in the ward’s ability to make decisions about matters affecting the ward’s health and safety?
b.When a decision has to be made about something for the ward (housing, medical care, education, employment, recreation, purchases, etc.), how are the decisions made?
(1)Describe decisions made by ward alone:
(2)Describe decisions made by guardian alone:
(3)Describe decisions made by guardian and ward together:
8.Community Resources (service providers, churches, government programs, charitable
organizations, etc.). List the community organizations that are currently involved with the ward.
Name of Organization
Services Received
Agency Phone
9.Significant Actions.
Describe any significant actions you have taken as guardian for the ward during the past
12 months:
You only have to fill out paragraphs 10 - 16 if you are a full guardian with authority to manage the ward’s finances. If you do not have financial management authority, skip to paragraph 17.
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10.Ward’s Annual Income. (List only the income of the ward during the 12–month reporting period. Do not list your income.)
Income Source
Annual Amount
Social Security Benefits:
Wages:
a. SSA:
Dividends/Interest:
b. SSI:
Rental Income:
Adult Public Assistance:
Pension:
Veterans Financial Benefits:
Annuities:
Alaska Longevity Bonus:
Other (describe):
Permanent Fund Dividend:
Native Corporation Dividend:
Total Annual Income:
Total Annual Income During Previous Reporting Period:
Change in Annual Income Since Previous Reporting Period
Explain any difference more than $1000:
11.Ward’s Annual Expenses. (Money paid to anyone on behalf of ward or ward’s legal dependents. Do not include your personal expenses. Attach extra pages if necessary.)
Expense
Description
Nursing/ Assisted Living Home:
Rent Payment:
Mortgage Payment:
Utilities:
Transportation:
Medical Treatment Costs
Medications:
Credit Card Payments:
Food:
Clothing:
Recreation or Entertainment:
Personal Expenses (include allowance):
Income Tax & Property Tax:
Home/Property Maintenance Costs:
Insurance
Home Insurance:
Auto Insurance:
Medical Insurance:
Life Insurance:
Gifts:
Child/Spousal Support:
Fees/Costs Paid to Guardian:
Other (list all other payments made):
Total Annual Expenses:
Total Annual Expenses During Previous Reporting Period:
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Change in Annual Expenses Since Previous Reporting Period Explain any difference more than $1000:
12.Money Controlled By Ward.
Does the ward have sole control over any money? If yes, please explain:
Is this money included in the income and expenses listed in #10 and #11? Explain:
13.
Ward’s Assets at the end of this Reporting Period (Date:
(List all assets the ward owns individually or jointly. Attach extra pages if necessary.)
a.
Cash on hand (not in an account) $
(amount)
(where located)
Explain any changes in the last 12 months:
Burial Account
Name of Bank or Institution
Type of
Account
Balance
Number
c.Alaska Native Corporation Dividend Account
Type of Account
Account Number
d.List all other bank accounts, certificates of deposit, etc. Attach the most recent bank statement. Attach additional pages if necessary.
Name(s) on
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e.List all Brokerage Accounts, Stocks, Bonds, and Other Securities. Attach the most recent account statement. Attach additional pages if necessary.
Name of Company
Name(s) on Account
Account Value on (date)
f.Retirement Accounts.
Beneficiary
Current Value
g.Ward’s Life Insurance Policies (policies the ward owns).
Beneficiary of Life
Face Value of Life Insurance
Cash Value of Life Ins.
h.Real Estate that Ward Owns (land and buildings). Attach tax assessment, if available.
(1)
Does ward own a home?
Yes. Estimated Value: $
Address:
Description:
Is there a joint owner?
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(2)
Other Real Estate.
Estimated Value: $
i.Vehicles. (List any cars, boats, snow machines, off-road vehicles, airplanes, etc.)
Type of Vehicle
Year, Make & Model
Value
Co-Owner
j.Furniture, Appliances and Electronic Equipment exceeding $400 in value. Attach additional pages if necessary.
Description of Item
Approximate Age
k.Jewelry, Gems, Precious Metals, Coin or Stamp Collections, Other Collections, Artwork, Raw or Decorated Ivory. Attach additional pages if
necessary.
Location
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