Form 4-996. Guardian's report.

[For use with Rule 1-140 NMRA] STATE OF NEW MEXICO COUNTY OF _______________ __________________ JUDICIAL DISTRICT In the matter of _______________________________, No. __________ a Protected Person. GUARDIAN’S REPORT Instructions. You must use this form, Form 4-996 NMRA, when you file a Guardian’s Report. The purpose of this Guardian’s Report is to give the court information about an adult for whom a guardian has been appointed. 1. You must complete and file this Guardian’s Report, as follows: a. Within ninety (90) days of your appointment as guardian by the court; b. Every year within thirty (30) days of the anniversary date of your appointment as guardian; c. Within thirty (30) days of your resignation, removal, or termination as guardian; and d. As otherwise ordered by the court. 2. Please type or print clearly using ink. 3. Complete all sections of this report that apply, and answer all questions thoroughly. 4. Attach additional pages if necessary. 5. After completing this report, you must sign it under penalty of perjury. 6. Copies of this report must be given to the Protected Person, the Protected Person’s conservator if one has been appointed, and any other persons specified by the court. 7. Keep a copy of this report for your records. 8. If you give financial information in Section (IV)(D) of this report, you must keep a copy of ALL of the Protected Person’s financial records for seven (7) years and make them available to the court upon request. TYPE OF REPORT: [ ] 90 day [ ] Annual [ ] Final Date of your appointment as guardian: ____________________________________ If this is a Final Report, please check the box below that explains why you are filing a Final Report, and fill in the requested information. If this is not a Final Report, skip to Section I. [ ] The Protected Person has died (attach a copy of the death certificate if available). Date and place of death: ____________________________________________ ________________________________________________________________ [ ] Name of personal representative, if appointed: ___________________________ Address: _________________________________________________________ ________________________________________________________________ [ ] The court has appointed a new guardian. Name of new guardian: _____________________________________________ Address and phone number of new guardian: ____________________________ ________________________________________________________________ [ ] The court has issued an order ending the guardianship. [ ] Other (please explain): ______________________________________________ SECTION I – Information about the Protected Person. A. Protected Person’s name: ___________________________________________ B. Protected Person’s age: ____________________________________________ C. Protected Person’s physical address: __________________________________ Mailing address (if different): _________________________________________ D. Protected Person’s telephone number(s) and other contact information: Home: ________________________ Cell: ______________________________ Work: __________________________ Fax: ______________________________ Email: ____________________________________________________________________ E. Has the Protected Person’s residence changed in the last 12 months? [ ] Yes [ ] No If yes, please explain why: ___________________________________________ ________________________________________________________________ ________________________________________________________________ F. Will the Protected Person’s residence change in the next 12 months? [ ] Yes [ ] No [ ] Unknown If yes, please explain why: ___________________________________________ ________________________________________________________________ ________________________________________________________________ G. Does the Protected Person live in a facility? [ ] Yes If yes, complete Part A, below (do not complete Part B). [ ] No If no, complete Part B, below (do not complete Part A). PART A Complete Part A only if the Protected Person lives in a facility. H. What type of facility does the Protected Person live in? [ ] Assisted Living Facility [ ] Group Home [ ] Licensed Nursing Facility [ ] Other (please explain) _________________________________________ ___________________________________________________________ I. Name of Facility: __________________________________________________ Facility contact person’s name: _______________________________________ Facility’s physical address: __________________________________________ Facility’s contact information: Telephone: ___________________ Email: ___________________________ J. How is the facility paid for? __________________________________________ K. Do you have any concerns about the quality of care that the Protected Person is receiving in the following areas? Cleanliness [ ] Yes [ ] No Nutrition/Meals [ ] Yes [ ] No Personal Care [ ] Yes [ ] No Privacy [ ] Yes [ ] No Individualized Care Plans [ ] Yes [ ] No Safety [ ] Yes [ ] No Other: ____________________ [ ] Yes [ ] No If you marked yes to any of the above, please explain: _____________________ ________________________________________________________________ ________________________________________________________________ L. Has the Protected Person been restricted from communicating, visiting, or interacting with others? [ ] Yes [ ] No If yes, describe the restrictions: _______________________________________ ________________________________________________________________ ________________________________________________________________ What are the reasons for the restrictions? _______________________________ ________________________________________________________________ ________________________________________________________________ Who imposed the restrictions? ________________________________________ When were the restrictions imposed? __________________________________ Are the restrictions still in place? [ ] Yes [ ] No M. Have others been restricted from communicating, visiting, or interacting with the Protected Person? [ ] Yes [ ] No If yes, describe the restrictions: _______________________________________ ________________________________________________________________ ________________________________________________________________ What are the reasons for the restrictions? _______________________________ ________________________________________________________________ ________________________________________________________________ Who imposed the restrictions? ________________________________________ When were the restrictions imposed? __________________________________ Are the restrictions still in place? [ ] Yes [ ] No N. Why was this facility chosen for the Protected Person? ____________________ ________________________________________________________________ ________________________________________________________________ O. How does the Protected Person feel about the placement? _________________ ________________________________________________________________ ________________________________________________________________ P. Do you believe the Protected Person could live and function more independently in a different type of setting? [ ] Yes [ ] No Please explain your answer: _________________________________________ ________________________________________________________________ ________________________________________________________________ Q. Have you tried to change the Protected Person’s residence in the past year? [ ] Yes [ ] No If yes, what was the outcome? ________________________________________ ________________________________________________________________ ________________________________________________________________ How does the Protected Person feel about the change of residence? _________ ________________________________________________________________ ________________________________________________________________ END OF PART A – If you filled out Part A, skip to Section II. PART B Complete Part B only if the Protected Person does not live in a facility. H. Describe the Protected Person’s living arrangement: ______________________ _______________________________________________________________ I. Does the Protected Person live with you? a. If yes, do you charge the Protected Person room and board? [ ] Yes [ ] No b. If yes, how much per month? ___________________ J. Who takes care of the Protected Person? _______________________________ Caregiver’s physical address: ________________________________________ Caregiver’s contact information: ______________________________________ Telephone: _____________________ Email: __________________________ K. Do you have any concerns about the quality of care that the Protected Person is receiving in the following areas? Cleanliness [ ] Yes [ ] No Nutrition/Meals [ ] Yes [ ] No Personal Care [ ] Yes [ ] No Privacy [ ] Yes [ ] No Safety [ ] Yes [ ] No Other: ___________________ [ ] Yes [ ] No If you marked yes to any of the above, please explain: _____________________ ________________________________________________________________ ________________________________________________________________ L. List all people living with the Protected Person and their relationship to the Protected Person: ________________________________________________________________ M. Has anyone moved into or out of the Protected Person’s residence during the last 12 months? [ ] Yes [ ] No If yes, please explain: ______________________________________________ ________________________________________________________________ N. List any person who lives with the Protected Person and is paid to provide services for the Protected Person. (attach additional pages if necessary) Name: __________________________________________________________ Relationship to Protected Person: _____________________________________ Types of Services: _________________________________________________ Payment: ____________ Source of Payment: ___________________________ O. Do you have concerns about anyone who lives with the Protected Person? [ ] Yes [ ] No If yes, please explain: ______________________________________________ ________________________________________________________________ ________________________________________________________________ P. Why was this living arrangement chosen for the Protected Person? ___________ ________________________________________________________________ ________________________________________________________________ Q. How does the Protected Person feel about the living arrangement? ________________________________________________________________ ________________________________________________________________ R. Do you believe the Protected Person could live and function more independently in a different type of setting? [ ] Yes [ ] No Please explain your answer: _________________________________________ ________________________________________________________________ ________________________________________________________________ S. Have you tried to change the Protected Person’s residence in the past year? [ ] Yes [ ] No If yes, what was the outcome? ________________________________________ ________________________________________________________________ ________________________________________________________________ How does the Protected Person feel about the change of residence? _________ ________________________________________________________________ ________________________________________________________________ T. Has the Protected Person been restricted from communicating, visiting, or interacting with others? [ ] Yes [ ] No If yes, describe the restrictions: _______________________________________ ________________________________________________________________ ________________________________________________________________ What are the reasons for the restrictions? _______________________________ ________________________________________________________________ ________________________________________________________________ Who imposed the restrictions? ________________________________________ When were the restrictions imposed? __________________________________ Are the restrictions still in place? [ ] Yes [ ] No U. Have others been restricted from communicating, visiting, or interacting with the Protected Person? [ ] Yes [ ] No If yes, describe the restrictions: _______________________________________ ________________________________________________________________ ________________________________________________________________ What are the reasons for the restrictions? _______________________________ ________________________________________________________________ ________________________________________________________________ Who imposed the restrictions? ________________________________________ When were the restrictions imposed? __________________________________ Are the restrictions still in place? [ ] Yes [ ] No END OF PART B – Continue to Section II. SECTION II - Protected Person’s Health. A. Please describe the Protected Person’s current physical health: [ ] Poor [ ] Fair [ ] Good [ ] Excellent Please explain:____________________________________________________ ________________________________________________________________ Please describe any changes to the Protected Person’s physical health in the last 12 months: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Please describe any medical treatment the Protected Person received in the last 12 months: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ B. Please describe the Protected Person’s current mental health: [ ] Poor [ ] Fair [ ] Good [ ] Excellent Please explain: ____________________________________________________ ________________________________________________________________ Please describe any changes to the Protected Person’s mental health in the last 12 months: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Please describe any mental health treatment the Protected Person received in the last 12 months: ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ C. Is the Protected Person under a healthcare provider’s regular care? [ ] Yes [ ] No If yes, please identify the Protected Person’s healthcare providers: Primary care provider: ______________________________________________ Dentist: __________________________________________________________ Mental health professional: __________________________________________ Other: ___________________________________________________________ D. How does the Protected Person feel about these healthcare providers? ________________________________________________________________ E. Do you attend the Protected Person’s medical and/or mental health appointments? [ ] Yes [ ] No If no, why not? ____________________________________________________ ________________________________________________________________ SECTION III - Protected Person’s Services and Activities. A. Is the Protected Person receiving support services, including public benefits? [ ] Yes [ ] No If yes, please list: __________________________________________________ ________________________________________________________________ B. Are you in regular contact with the Protected Person’s support-service providers? [ ] Yes [ ] No If yes, how often and in what manner? _________________________________ ________________________________________________________________ If no, why not? ____________________________________________________ ________________________________________________________________ C. Is the Protected Person involved in selecting the Protected Person’s services? [ ] Yes [ ] No If no, please explain: _______________________________________________ ________________________________________________________________ D. Is the Protected Person involved in developing the Protected Person’s care plan or service plan? [ ] Yes [ ] No If no, why not? ____________________________________________________ ________________________________________________________________ E. Does the Protected Person participate in social activities, such as family gatherings, local events, worship services, or community groups? [ ] Yes [ ] No If yes, please describe: _____________________________________________ ________________________________________________________________ ________________________________________________________________ If no, why not? ____________________________________________________ ________________________________________________________________ SECTION IV - Protected Person’s Financial Status. A. Does the Protected Person have a conservator? [ ] Yes [ ] No If yes, what is the conservator’s name and contact information? _____________ ________________________________________________________________ B. Are you responsible for the Protected Person’s money in your role as guardian? [ ] Yes [ ] No If yes, are you keeping the Protected Person’s money and your money in separate accounts? [ ] Yes [ ] No If you are responsible for the Protected Person’s money, you must keep the Protected Person’s money in a separate account from yours and that of others. If you are not doing this, why not? __________________________________ ________________________________________________________________ C. Are you responsible for the Protected Person’s money in any other capacity or role (e.g., Representative Payee, VA Fiduciary, Power of Attorney, Trustee)? [ ] Yes [ ] No If yes, please describe: _____________________________________________ ________________________________________________________________ If you are not responsible for the Protected Person’s money in any other capacity or role, the name, role, and contact information for those who are: _______________________________________________________________ D. If you are responsible for the Protected Person’s money, please complete the following summary of financial activity since your appointment or last report: Balance of Protected Person’s bank accounts on date of your appointment or last report (savings, checking, CDs, money market, etc.) $ Plus (+) annual money received from any source on behalf of the Protected Person (Social Security, SSI, pension, disability, interest, etc.) + Less (-) annual total fees to care providers - Less (-) annual total monies paid to the Protected Person (personal needs, etc.) - Less (-) annual total fees paid to guardian - Less (-) annual any other expenses (room and board, housing, insurance, maintenance, etc.) - Ending balance of bank accounts $ If you are responsible for the Protected Person’s money, you must keep a copy of ALL of the Protected Person’s financial records for seven years and make them available to the court upon request. E. Is the Protected Person employed? [ ] Yes [ ] No If yes, identify the Protected Person’s employer, job title, and wages: _________ ________________________________________________________________ Does the Protected Person have control of these wages? [ ] Yes [ ] No If no, why not? ____________________________________________________ ________________________________________________________________ F. Describe efforts to allow the Protected Person to make financial decisions: _____ ________________________________________________________________ ________________________________________________________________ G. Have there been any significant changes in the Protected Person’s ability to manage finances? [ ] Yes [ ] No If yes, describe: ___________________________________________________ ________________________________________________________________ H. Have there been any significant changes in the Protected Person’s financial situation, such as a settlement, inheritance, lottery winnings, reverse mortgage, etc.? [ ] Yes [ ] No If yes, describe: ___________________________________________________ ________________________________________________________________ SECTION V – Information about the Guardianship. A. Describe significant decisions you have made for the Protected Person in the last 12 months (e.g., change in healthcare providers, enrollment in hospice, discontinuation of treatment, surgery, etc.): ______________________________ ________________________________________________________________ ________________________________________________________________ B. How often and in what way(s) are you in contact with the Protected Person? ___ ________________________________________________________________ ________________________________________________________________ C. When was the last time you were in contact with the Protected Person? _______ ________________________________________________________________ D. Describe any significant problems or unmet needs of the Protected Person not described elsewhere: _______________________________________________ ________________________________________________________________ ________________________________________________________________ E. Does the Protected Person believe that the guardianship should be changed or terminated? [ ] Yes [ ] No If yes, please explain: ______________________________________________ ________________________________________________________________ Have you informed the Protected Person that the Protected Person may contact the court to request changing or terminating the guardianship? [ ] Yes [ ] No If no, why not? ____________________________________________________ ________________________________________________________________ F. Do you believe that the guardianship should be changed or terminated? [ ] Yes [ ] No If yes, you have a duty to file a separate written request asking the court to schedule a status conference to review the guardianship. G. How does the Protected Person feel about the guardianship? _______________ ________________________________________________________________ ________________________________________________________________ H. Is there anything else you would like to tell the court about the guardianship? ___ ___________________________________________________________________ ___________________________________________________________________ SECTION VI – Information about the Guardian. For purposes of this section, “guardian” means an individual or a corporate entity appointed by the court, and includes any individual working for a corporate entity who is responsible for the Protected Person. A. Do you serve as guardian for more than two non-family members? [ ] Yes [ ] No B. If yes, are you certified with the Center for Guardianship Certification? [ ] Yes [ ] No If yes, please attach a copy of your Certification to this report. C. Does the guardian have any significant physical or mental health problems that would interfere with the ability to continue as guardian in the next year? [ ] Yes [ ] No If yes, please explain: _________________________________________________ ___________________________________________________________________ D. Does the guardian charge a fee or receive payment for acting as the Protected Person’s guardian? [ ] Yes [ ] No If yes, how much have has the guardian received since the guardian’s last report (or since the guardian’s appointment if this is the guardian’s first report)? ___________________________________________________________________ How is the guardian’s fee or payment calculated? ___________________________ ___________________________________________________________________ Who pays the guardian’s fee? ___________________________________________ E. Since the guardian’s last report (or since the guardian’s appointment if this is the guardian’s first report), has the guardian, 1. Been arrested for, charged with, or convicted of any felony or misdemeanor? [ ] Yes [ ] No If yes, please explain: _________________________________________ ___________________________________________________________ ___________________________________________________________ 2. Been investigated by the Children, Youth and Families Department (CYFD), Adult Protective Services (APS), Internal Revenue Service (IRS), or any other governmental agency? [ ] Yes [ ] No If yes, please explain: _________________________________________ ___________________________________________________________ ___________________________________________________________ 3. Filed for bankruptcy or received protection from creditors? [ ] Yes [ ] No If yes, please explain: _________________________________________ ___________________________________________________________ ___________________________________________________________ 4. Had any professional or occupational license revoked or suspended? [ ] Yes [ ] No If yes, please explain: _________________________________________ ___________________________________________________________ ___________________________________________________________ 5. Had the guardian’s driver’s license suspended or revoked? [ ] Yes [ ] No If yes, please explain: _________________________________________ ___________________________________________________________ ___________________________________________________________ 6. Delegated any powers over the Protected Person to another person? [ ] Yes [ ] No If yes, who were power(s) delegated to? __________________________ What power(s) were delegated? _________________________________ For what period(s) of time? _____________________________________ 7. Received any special training or certification as a guardian? [ ] Yes [ ] No If yes, please explain: _________________________________________ ___________________________________________________________ F. Is the guardian a court-appointed guardian or conservator for any other person? [ ] Yes [ ] No If yes, please list the court and case number(s) for each (attach additional pages if necessary): _____________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ AFFIRMATION UNDER PENALTY OF PERJURY I, __________________________, am the guardian of __________________________, and I affirm under penalty of perjury under the laws of the State of New Mexico that the information in this report is true and correct. Date Submitted: __________________________ ____________________________________ Guardian’s Signature ____________________________________ Typed/Printed Name ____________________________________ Street or Post Office Address ____________________________________ City, State and Zip Code ____________________________________ Telephone Number(s) ____________________________________ Fax Number ____________________________________ Email Is this a change in address from your previous report? [ ] Yes [ ] No CERTIFICATE OF SERVICE I certify that on (date) ______________________ I served a copy to the following individuals: [ ] Protected Person _____________________________________ _____________________________________ _____________________________________ _____________________________________ [ ] By mail or other delivery service [ ] By fax (number) _________________ [ ] By hand delivery [ ] By e-mail [ ] Person(s) designated by court order (name and address): _____________________________________ _____________________________________ _____________________________________ _____________________________________ [ ] By mail or other delivery service [ ] By fax (number) _________________ [ ] By hand delivery [ ] By e-mail _____________________________________ _____________________________________ _____________________________________ _____________________________________ [ ] By mail or other delivery service [ ] By fax (number) _________________ [ ] By hand delivery [ ] By e-mail _____________________________________ _____________________________________ _____________________________________ _____________________________________ [ ] By mail or other delivery service [ ] By fax (number) _________________ [ ] By hand delivery [ ] By e-mail _____________________________________ _____________________________________ _____________________________________ _____________________________________ [ ] By mail or other delivery service [ ] By fax (number) _________________ [ ] By hand delivery [ ] By e-mail ________________________________________ Typed/Printed Name ________________________________ Guardian’s Signature