FORM 27.7M – ANNUAL GUARDIANSHIP PLAN 3/01/17

PROBATE COURT OF MONTGOMERY COUNTY, OHIO ALICE O. McCOLLUM, JUDGE

GUARDIANSHIP OF:

CASE NO.:

ANNUAL GUARDIANSHIP PLAN [SUP.R.66.08(G)]

INSTRUCTIONS: If you are the guardian of the person only, fill out Sections I and II and sign on the Guardian’s Signature blank.

If you are the guardian of the estate only, fill out Sections I and III and sign on the Guardian’s Signature blank.

If you are the guardian of the person and estate, fill out Sections I, II, and III and sign on the Guardian’s Signature blank.

SECTION I. WARD’S INFORMATION

A. Date of BirthThe ward was born on:

MM/DD/YYYY

B. Medical ConditionsThe ward has been diagnosed with the following medical conditions:

☐ Dementia

☐ Developmental disabilities

☐ Mental illness

☐ Substance abuse

☐ Traumatic brain injury

☐ Other:

C. Functional AbilitiesRate the ward’s ability to perform the following tasks:

No assistance needed

Some assistance needed

Maximum assistance needed

Bathing ☐ ☐ ☐

Grooming ☐ ☐ ☐

Dressing ☐ ☐ ☐

Eating ☐ ☐☐

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FORM 27.7M – ANNUAL GUARDIANSHIP PLANPAGE 2 3/01/17

Toileting ☐ ☐ ☐

Using telephone ☐ ☐ ☐

Getting up from bed ☐ ☐ ☐

Driving ☐ ☐ ☐

Preparing meals ☐ ☐ ☐

Shopping ☐ ☐ ☐

Housework ☐ ☐ ☐

Managing medications ☐ ☐ ☐

Managing money ☐ ☐ ☐

SECTION II. WARD’S PERSONAL NEEDS

A. Housing NeedsThe ward has lived in the following during the past year:

☐ Ward’s own home

☐ Family member’s or friend’s home

☐ Foster, group, or boarding home

☐ Nursing home

☐ Medical facility or state institution

☐ Other:

B. Medical NeedsThe ward has received the following medical care during the past year:

☐ Regular examination or treatment by a primary care physician

☐ Regular examination or treatment by a dentist

☐ Regular examination or treatment by a mental health care provider

☐ Emergency examination or treatment

☐ Surgery

☐ Other:

C. Personal Care Needs

The ward has received personal care, such as bathing, grooming and feeding, from thefollowing persons during the past year:

☐ Family members or friends

☐ Home health care providers

CASE NO. ____________________

FORM 27.7M – ANNUAL GUARDIANSHIP PLAN PAGE 3 3/01/17

☐ Nursing home, medical facility, or institutional health care providers

☐ Other:

D. Social NeedsThe ward has received or participated in the following activities during the past year:

☐ Visits with family members or friends

☐ Recreational activities

☐ Educational activities

☐ Vocational training

☐ Other:

E. Community ServicesThe ward has received the following community services during the past year:

☐ Sheltered workshop

☐ Adult day care

☐ Senior center

☐ Transportation

☐ Meal delivery

☐ Other:

F. GoalsI plan to do the following to ensure that the ward’s housing, medical, personal care, and socialneeds are met during the next year:

CASE NO. ____________________

FORM 27.7M – ANNUAL GUARDIANSHIP PLANPAGE 4 3/01/17

SECTION III WARD’S FINANCIAL NEEDS

A. Value of EstateThe value of the ward’s estate is:

Total value of personal property $_______________

Total value of real property $_______________

Annual rent on real property $_______________

Other annual income $_______________

Total $_______________

B. GoalsI plan to do the following to ensure that the ward’s financial needs are met during the next year:

Under penalties of perjury, I declare that I have read the foregoing and the facts alleged are true, to the best of my knowledge and belief.

Date Guardian’s Signature

Guardian’s Printed Name