IN THE SUPERIOR COURT FOR THE STATE OF ALASKA

AT ____________________

In the Matter of the Protective Proceedings of:	)

)

)

)	Case No:

,	)

Respondent	)	COURT VISITOR’S REPORT ON

)	INITIAL PETITION

I,	, was appointed as the Court Visitor in the matter of the petition for the respondent named above. I submit the following report under Alaska Probate Rule 16(g)(2), Alaska Probate Rule 17(g)(2), AS 13.26.236, and/or AS 13.26.515 in anticipation of the hearing, currently scheduled for	,	:

Did you use an interpreter to communicate with Respondent?

No	Yes, someone interpreted to and from the following language:	.	[If yes, please inform the court of the need for an interpreter.]

NOTICE

1.	Did you explain to Respondent the purpose of the petition and tell Respondent the date, time, and place of the hearing?

Yes	No

2.	Did you give a copy of the petition to Respondent?

Yes	No

3.	Did you explain Respondent’s rights, including the right to an attorney and to have an attorney present during your interview, and provide Respondent with the Notice of Respondent’s Rights Before Visitor’s Interview, PG-290?

Yes	No

4.	Did you provide any family members who are interested in serving as a guardian or conservator with Important Information for Guardians and Conservators, PG-291?

Yes	No

5.	I was unable to provide the notices marked “No” above, because:

CONTACTS

1.	List all contacts or attempted contacts made and the method of contact.

[Attach extra pages if necessary.]

Name	Relationship to Respondent	Address	Phone/Email	How was contact made?

2.	Do the opinions of the individuals contacted support the conclusions of this report?

C.	LIFE HISTORY

1.	Respondent was born in

Respondent grew up in

Respondent has lived in Alaska for	year(s). months.

2.	Respondent is: Never Married Currently Married Divorced Widowed

3.	Does Respondent have children, parents, siblings, or other relatives living nearby?

4.	Is Respondent a veteran? No Yes [If yes, notify VA by letter and hearing notice.]

5.	What is Respondent’s current employment (if any) and employment history?

6.	Were there any important details about Respondent’s life history that you were unable to learn about or verify? No Yes [If yes, explain below.]

7.	Why did the petitioner decide to file for guardianship or conservatorship?

D.	MEDICAL RECORDS, TESTS, AND EXAMINATIONS

1.	List all medical or mental health records you have reviewed that are relevant to your recommendation. In the last column, indicate whether these records were included in the petition and/or are attached to your report. [Attach extra pages if necessary.]

Type of Record	Source	Date Created	Copy Attached?
Pet. Report
Pet. Report
Pet. Report
Pet. Report
Pet. Report
Pet. Report

I was unable to review medical or mental health records, because:

Medical Status. Describe Respondent’s medical diagnoses, needs, and overall medical condition, and how it is relevant to the need for a court order:

Mental and Emotional Status. Describe Respondent’s mental health diagnoses, needs, and overall emotional status, and how it is relevant to the need for a court order:

4.	Physical Condition. Describe Respondent’s physical condition and needs (including physical, occupational, speech-language, etc. therapy; medication; and assistance with daily activities such as bathing, dressing, or ambulation):

5.	Adaptive Abilities. Describe Respondent’s ability to adapt to change or conflict and any associated behaviors, and how it is relevant to the need for a court order:

6.	Educational, Vocational, Recreational, and Social Skills. Describe Respondent’s current abilities and activities. State whether Respondent would benefit from specific assistance and, if known, whether that assistance is available:

E.	DAY-TO-DAY NEEDS

1.	Housing. Describe Respondent’s current housing arrangements and any potential changes:

2.	Services. Describe the type and extent of current services Respondent receives or could receive to maintain health, safety, and well-being: [Please be specific and give examples about the proposed plans to address Respondent’s needs, such as Medicaid waiver program, vocational programs, in-home services, etc. Also include whether any of these services require out-of-state placement.]

F.	FINANCIAL INFORMATION

1.	Current Monthly Income.

[List only Respondent’s current income. Attach extra pages if necessary.]

Income Source	Amount	Income Source	Amount
Social Security Benefits:	Wages/Salary:
Adult Public Assistance:	Dividends/Interest:
Veterans Financial Benefits:	Rental Income:
Senior Care Benefit:	Pension:
Permanent Fund Dividend:	Annuities:
Native Corporation Dividend [list name(s) of corporation(s)]:	Other:
Other:	Other:

Total Current Monthly Income:	$

I was unable to determine or verify current income, because:

2.	Future Monthly Income.

[List any income Respondent will be eligible for if a protective order is issued.]

Income Source	Amount	Income Source	Amount

I was unable to determine future income, because:

3.	Current Monthly Expenses.

[List only Respondent’s current expenses. Attach extra pages if necessary.]

Expense	Amount	Expense	Amount
Nursing/Assisted Living Home:	Utilities:
Rent or Mortgage Payment:	Food:
Taxes:	Clothing:
Home/Property Maintenance:	Transportation:
Home or Renter’s Insurance:	Auto Insurance:
Medication/Medical Treatment:	Recreation/Hobbies:
Medical Insurance:	Personal Care/Hygiene:
Life Insurance:	Child/Spousal Support:
Other:	Other:

Total Current Monthly Expenses:	$

I was unable to determine or verify current expenses, because:

4.	Assets.

[List all assets Respondent owns individually or jointly. Attach extra pages if necessary.]

a.	Cash on Hand (not in an account) $

Amount	Where Located

b.	Bank Accounts

[Include in the third column how many months of statements that you reviewed for each account. Attach most recent statement reviewed for the account.]

Name of Bank or Institution	Type of Account (Checking, Savings, etc.)	No. of Mos. Re-viewed	Account No.	Balance

c.	Alaska Native Corporation Dividend Account

[Attach most recent statement reviewed for the account.]

Name of Bank or Insitution	Type of Account	Account No.	Balance

d.	Brokerage Accounts, Stocks, Bonds, and Other Securities

[Attach most recent statement reviewed for each account.]

Name of Company	Name(s) on Account	Date of Balance	Balance

e.	Retirement Accounts [Attach most recent statement reviewed for each account.]

Name of Company	Beneficiary	Current Value

f.	Life Insurance Policies [Attach most recent statement reviewed for each policy.]

Name of Company	Beneficiary	Face Value	Cash Value

g.	Burial Account [Attach most recent statement reviewed for the account.]

Name of Bank or Insitution	Type of Account	Account No.	Balance

h.	Did you review bank records and are there any concerns?

I reviewed the bank records, and I have no concerns.

I reviewed the bank records, and I have concerns about:

I was unable to review the bank records, because:

i.	Real Estate (land and buildings)

(1)	Does Respondent own a home?	No	Yes	Estimated Value: $

Address:

Description:

Is there a joint owner?	No	Yes, Name of Co-Owner:

(2) Other Real Estate.	Estimated Value: $

Address:

Description:

Is there a joint owner? No Yes, Name of Co-Owner:

j.	Vehicles [Cars, trucks, boats, snow machines, airplanes, etc.]

Type of Vehicle	Year, Make, and Model	Co-Owner	Value

k.	Other Valuable Personal Property [Other significant assets that you learned about (valuable licenses, antiques, collectables, art, etc.). Estimate value if unknown.]

Description	Location	Value

Total Assets at Time of Report:	$

5.	Liabilities.

[List all debts Respondent owes, including mortgages, loans, credit card debt, overdue bills, judgments/liens, etc. Attach extra pages if necessary.]

a.	Real Estate Debts.

(1) Home described in #4(i)(1).	Loan balance: $

(2) Property described in #4(i)(2).	Loan balance: $

b.	Other Loans and Debts

To Whom Owed [Name of creditor or credit card company]	Debt/Loan Type Description	Balance Due

Total Liabilities at Time of Report:	$

6.	Financial Narrative. Is there any additional information about Respondent’s financial situation that would be helpful to the court?

7.	Financing. Briefly describe how the services that are recommended to benefit Respondent will be paid for. Include any costs or fees associated with a guardianship/conservatorship, or with any less-restrictive arrangement such as alternate payee. [For example, whether Respondent can pay with Respondent’s own funds, whether the guardian or conservator needs to apply for government benefits, etc.]

G.	CONFLICT MITIGATION

Are there any conflicts of interest that may be alleviated by court order per AS 13.26.311?

[For example, the proposed guardian/conservator is Respondent’s creditor, landlord, business partner, personal care assistant (PCA), employer, or similar.]

JUSTIFICATION FOR RECOMMENDATIONS

Prognosis. Describe whether and how Respondent’s condition may improve in the future:

2.	Alternatives to Guardianship or Conservatorship.

Check the alternatives that you recommend:

Representative payee and/or other community services

Power of attorney

Supported decision-making agreement

Limited guardianship or conservatorship order

Other:

b.	If you are not recommending any alternatives listed in section a, describe less-restrictive options that have been tried, have failed, or are not feasible:

c.	Do you recommend a review or reevaluation, because Respondent’s condition may improve and permit less restrictive alternatives or removal of a guardianship or conservatorship in the future?

No	Yes, after	year(s). months.

3.	Public Guardian or Private Professional Recommendation.

a.	If you recommend an OPA Public Guardian—the appointment of last resort—please describe alternatives you decided are not available or feasible:

I am not recommending appointment of an OPA Public Guardian.

If this is a public guardian or private professional appointment, please attempt to provide the following information about Respondent:

Date and Place of Birth:

(2)	Mother’s Maiden Name:

(3)	Please also provide Respondent’s social security number, but do not record it here. Instead, bring the information to the guardianship or conservatorship hearing.

I.	BACKGROUND OF GUARDIAN OR CONSERVATOR

1.	Briefly describe the proposed guardian or conservator and that person’s relationship to Respondent:

2.	Is the proposed guardian or conservator employed?

No	Not applicable—OPA or professional guardian proposed

Yes, and the person works as

3.	Does the proposed guardian or conservator report felony or other criminal convictions, barrier crimes, small claims cases, theft, fraud, assault, or bankruptcy?

No	Not applicable—OPA or professional guardian proposed

Yes. The person reported

4.	Did you check Courtview for court cases involving the proposed guardian or conservator?

No	Not applicable—OPA or professional guardian proposed

Yes. I found

5.	Do you recommend any limitations or special provisions in the order due to a criminal or civil matter?

No	Not applicable—OPA or professional guardian proposed

Yes. The order should provide that

6.	If you recommend a professional guardian or conservator, does the professional have a current license? No Yes Not applicable—non-professional recommended

7.	Does the private guardian or conservator have liability insurance?

No Yes [Please attach the fee schedule to this report.]

Not applicable—non-professional recommended

J.	EXPERT APPOINTMENT

The court has already appointed an expert in this case.

The expert has already provided a report, either by established records or after a court-ordered evaluation (date of report:	). The report is attached to the petition. this visitor report. other:

The expert has not yet provided a report, because

My review of the existing records provides sufficient information for me to identify the following established provider as a potential expert:

Name

Phone Number	Email

This provider previously evaluated Respondent on	[date]. A report and/or medical records dated	is/are attached to the petition. this visitor report. other:

There are no established reports or records on the issue of Respondent’s alleged incapacity. The court should order this provider to perform an evaluation of Respondent.

The existing records do not provide sufficient information for me to identify an established provider as a potential expert. The court should order an evaluation of Respondent and allow me time to investigate an appropriate provider and arrange for this evaluation. I will file a report of the evaluation with the court.

K.	ANY ADDITIONAL OBSERVATIONS OR RECOMMENDATIONS:

SUMMARY OF RECOMMENDATIONS

The Court Visitor recommends the following least-restrictive arrangements to protect Respondent from injury, illness, and disease, provide for treatment, and protect Respondent’s financial interests:

No guardianship or conservatorship is appropriate. Instead, the court should:

The court should appoint	to serve as guardian. co-guardians. conservator. co-conservators.

The guardian or conservator should have: full authority. authority only over decisions about:

In addition to the above guardian(s), the court should appoint	as a separate conservator.

2.	The following specific authority:

Room and Board (rent, utilities, and food) authorization of $	per month.

can also be a paid provider under Medicaid.

Other recommendations:

3.	With respect to the education requirement:

The guardian/conservator must complete this requirement and submit form PG-120, Affirmation of Education, within 30 days after the court issues the appointment order.

The guardian or conservator has already completed and filed proof of this requirement.

Not Applicable—private professional or public guardian is recommended.

4.	The guardian must file a Guardianship Plan within 30 days after the court issues the	appointment order. Conservators-only are not required to file this plan.

5.	The guardian and/or conservator must file an Implementation Report within 90 days after the court issues the appointment order.

6.	Annual Reports in this case should always cover the twelve-month period beginning the first day of	[month] and ending the last day of	[month]. The annual report is due within 30 days after the end of the reporting period.

Date	Signature of Court Visitor

Phone Number	Print or Type Name

Email Address	Address

I certify that on	at	[date/time], I mailed hand-delivered emailed

a copy of this report to:

Petitioner	Respondent (through attorney) Proposed Guardian Proposed Conservator

Other:

Signature of Court Visitor: