New Mexico Forms Library

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:           c 90-day       c Annual      c Final

 

Date of your appointment as guardian: ____________________________________

 

 

 

c        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:  ___________________________________________________

___________________________________________________________

c        The court has appointed a new guardian.

Name of new guardian: ________________________________________

Address and phone number of new guardian:  ______________________

___________________________________________________________

c        The court has issued an order ending the guardianship.

c        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?

c Yes             c No

If yes, please explain why: __________________________________________

________________________________________________________________

________________________________________________________________

F.         Will the Protected Person’s residence change in the next 12 months?

c Yes                        c No              c Unknown

If yes, please explain why: ___________________________________________

________________________________________________________________

________________________________________________________________

G.        Does the Protected Person live in a facility?     

c Yes            If yes, complete Part A, below (do not complete Part B).

c 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?

c        Assisted Living Facility

c        Group Home

c        Licensed Nursing Facility

c        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                                       c Yes                        c No

Nutrition/Meals                                 c Yes                        c No

Personal Care                                  c Yes                        c No

Privacy                                               c Yes                        c No

Individualized Care Plans              c Yes                        c No

Safety                                                 c Yes                        c No

Other: _____________________ c Yes                        c 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?      c Yes            c 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?   c Yes                        c No

M.        Have others been restricted from communicating, visiting, or interacting with the Protected Person?                c Yes                 c 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?   c Yes                        c 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?            c Yes             c No

Please explain your answer: _________________________________________

________________________________________________________________

________________________________________________________________

Q.        Have you tried to change the Protected Person’s residence in the past year?                     c Yes                        c 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?

c Yes            c 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                                       c Yes                        c No

Nutrition/Meals                                 c Yes                        c No

Personal Care                                  c Yes                        c No

Privacy                                               c Yes                        c No

Safety                                                 c Yes                        c No

Other: _____________________ c Yes                        c 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? c Yes             c 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?

c Yes c 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?            c Yes             c No

Please explain your answer: _________________________________________

________________________________________________________________

________________________________________________________________

S.        Have you tried to change the Protected Person’s residence in the past year?                     c Yes            c 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?       c Yes                        c 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?   c Yes                        c No

U.        Have others been restricted from communicating, visiting, or interacting with the Protected Person?    c Yes                        c 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?               c Yes                        c 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:

c Poor           c Fair                        c Good         c 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:

c Poor           c Fair                        c Good         c 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?

c Yes             c 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?         c Yes                        c No

If no, why not? ____________________________________________________

________________________________________________________________

 

SECTION III - Protected Person’s Services and Activities.

 

A.        Is the Protected Person receiving support services, including public benefits?       c Yes                        c No

If yes, please list: __________________________________________________

________________________________________________________________

B.        Are you in regular contact with the Protected Person’s support-service providers? c Yes                        c 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?     c Yes                        c No

If no, please explain: _______________________________________________

________________________________________________________________

D.        Is the Protected Person involved in developing the Protected Person’s care plan or service plan?                    c Yes                 c 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?   c Yes            c No

If yes, please describe: _____________________________________________

________________________________________________________________

________________________________________________________________

If no, why not? ____________________________________________________

________________________________________________________________

 

SECTION IV - Protected Person’s Financial Status.

A.        Does the Protected Person have a conservator?          c Yes             c 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? c Yes                        c No

If yes, are you keeping the Protected Person’s money and your money in separate accounts?  c Yes                       c No

 

 

 

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)?        c Yes                        c 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	$

            E.        Is the Protected Person employed?                     c Yes                        c No

If yes, identify the Protected Person’s employer, job title, and wages:                                                                                                                                                                      

Does the Protected Person have control of these wages?      c Yes           c 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?            c Yes                        c 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.?              c Yes                        c 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?     c Yes                        c 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?

            c Yes                        c No

If no, why not? ____________________________________________________

________________________________________________________________

F.         Do you believe that the guardianship should be changed or terminated?

c Yes                        c 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?

c Yes c No

B.        If yes, are you certified with the Center for Guardianship Certification?

c Yes                        c 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?

            c Yes                        c No

If yes, please explain: ______________________________________________

________________________________________________________________

            D.        Does the guardian charge a fee or receive payment for acting as the Protected Person’s guardian?    c Yes                        c 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?        c Yes             c 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?

c Yes                        c No

If yes, please explain: _________________________________________

___________________________________________________________

___________________________________________________________

                        3.         Filed for bankruptcy or received protection from creditors?

c Yes                        c No

If yes, please explain: _________________________________________

___________________________________________________________

___________________________________________________________

4.         Had any professional or occupational license revoked or suspended?

c Yes                        c No

If yes, please explain: _________________________________________

___________________________________________________________

___________________________________________________________

                        5.         Had the guardian’s driver’s license suspended or revoked?

c Yes                        c No

If yes, please explain: _________________________________________

___________________________________________________________

___________________________________________________________

                        6.         Delegated any powers over the Protected Person to another person?

c Yes                        c 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?

c Yes                        c No

If yes, please explain: ____________________________________________

______________________________________________________________

            F.        Is the guardian a court-appointed guardian or conservator for any other person? c Yes             c 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?            c Yes                        cNo

 

CERTIFICATE OF SERVICE

 

            I certify that on (date) ______________I served a copy to the following individuals:

 

c  Protected Person             ___________________________             ___________________________             ___________________________             ___________________________       c  Person(s) designated by court order (name and address):             ___________________________             ___________________________             ___________________________             ___________________________                 ___________________________             ___________________________             ___________________________             ___________________________

c   By mail or other delivery service c   By fax (number) _____________ c   By hand delivery c   By e-mail         c   By mail or other delivery service c   By fax (number) _____________ c   By hand delivery c   By e-mail   c   By mail or other delivery service c   By fax (number) _____________ c   By hand delivery c   By e-mail

___________________________             ___________________________             ___________________________             ___________________________                   ___________________________             ___________________________             ___________________________             ___________________________       _________________________________ Typed/Printed Name

c   By mail or other delivery service c   By fax (number) _____________ c   By hand delivery c   By e-mail     c   By mail or other delivery service c   By fax (number) _____________ c   By hand delivery c   By e-mail       ______________________________ Guardian’s Signature

 

[Approved by Supreme Court Order No. 18-8300-005, effective for all cases on or after July 1, 2018; as amended by Supreme Court Order No. 21-8300-003, effective June 22, 2021.]