Report of Abuse, Neglect or Exploitation of Ward

Guardianship of Case number Short statement describing the alleged abuse, neglect, or exploitation line 1 Short statement describing the alleged abuse, neglect, or exploitation line 2 Short statement describing the alleged abuse, neglect, or exploitation line 3 Short statement describing the alleged abuse, neglect, or exploitation line 4 Short statement describing the alleged abuse, neglect, or exploitation line 5 Short statement describing the alleged abuse, neglect, or exploitation line 6 Short statement describing the alleged abuse, neglect, or exploitation line 7 Short statement describing the alleged abuse, neglect, or exploitation line 8 Short statement describing the alleged abuse, neglect, or exploitation line 9 Short statement describing the alleged abuse, neglect, or exploitation line 10 Short statement describing the alleged abuse, neglect, or exploitation line 11 Short statement describing the alleged abuse, neglect, or exploitation line 12 Short statement describing the alleged abuse, neglect, or exploitation line 13 Continued on separate sheet attached to this request

The events in the preceding allegation took place

Specific date Over a period from and to Period from Period to Beginning on and continuing to this day

Beginning on

Agencies the events were reported to

None Police or Sheriff Adult Protective Services Board of Developmental Disabilities Other

Other agency Attached are copies of agency reports or other information The Guardian does not have any agency reports or other information to provide

There are no witnesses Witness one name Witness one relationship to ward Witness two name Witness two relationship to ward Witness three name Witness three relationship to ward Continued on separate sheet attached to this report Date