Oregon Revised Statutes Protective Proceedings; Powers of Attorney; Trusts § 125.325

1. My name is __________.

2. My address and telephone number are:

__________

__________

Phone __________

3. The name, if applicable, and address of the place where the person now resides are:

__________

__________

4. The person is currently residing at the following type of facility or residence:

__________

5. The person is currently engaged in the following programs and activities and receiving the following services (brief description):

__________

6. I was paid for providing the following items of lodging, food or other services to the person:

__________

__________

7. The name of the person primarily responsible for the care of the person at the person's place of residence is:

__________

8. The name and address of any hospital or other institution where the person is now admitted on a temporary or permanent basis are:

__________

__________

9. The person's physical condition is as follows (brief description):

__________

__________

10. The person's mental condition is as follows (brief description):

__________

__________

11. I made the following contacts with the person during the past year (brief description):

__________

12. I made the following major decisions on behalf of the person during the past year (brief description):

__________

13. I believe the guardianship should or should not continue because:

__________

14. At the time of my last report, I held the following amount of money on behalf of the person: $__________. Since my last report, I received the following amount of money on behalf of the person: $__________. I spent the following amount of money on behalf of the person: $__________. I now hold the following amount of money on behalf of the person: $__________.

15. A true copy of this report will be given to the person, any conservator for the person and any other person who has requested notice.

16. Since my last report:

__________

17. Since my last report, I have delegated the following powers over the protected person for the following periods of time (provide name of person powers delegated to):

__________

I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury.

Dated this ___ day of __________, 2___.