Ward's Supplemental Information Form - Fairfield County Court of Common Pleas (Fillable)

Guardianship of Case number Initial guardian Successor guardian Name of current or prior guardian Full legal name Also known as Age Date of birth Married Not married Relationship with family excellent Relationship with family good Relationship with family fair Relationship with family poor Family members relationship excellent Family members relationship good Family members relationship fair Family members relationship poor Ward aware yes Ward aware no The proposed ward's home Someone else's home An assisted living facility A nursing home Other Other location Street City State Zip How long at location years How long at location months Leaves location regularly yes Leaves location regularly no If yes explain line 1 If yes explain line 2 If yes explain line 3

Case number Ward telephone number Ward does not have a telephone Best contact name Best contact street Best contact city Best contact state Best contact zip Best contact daytime telephone number Relative or friend 1 name Relative or friend 1 relationship Relative or friend 1 street Relative or friend 1 city Relative or friend 1 state Relative or friend 1 zip Relative or friend 1 daytime telephone number Relative or friend 2 name Relative or friend 2 relationship Relative or friend 2 street Relative or friend 2 city Relative or friend 2 state Relative or friend 2 zip Relative or friend 2 daytime telephone number Relative or friend 3 name Relative or friend 3 relationship Relative or friend 3 street Relative or friend 3 city Relative or friend 3 state Relative or friend 3 zip Relative or friend 3 daytime telephone number Agency name 1 Agency contact person 1 Agency telephone number 1 Agency name 2 Agency contact person 2 Agency telephone number 2 Agency name 3 Agency contact person 3 Agency telephone number 3

Case number Court-appointed conservator yes Court-appointed conservator no Conservator's name Conservator's phone Conservator court Conservator case number Court-appointed guardian yes Court-appointed guardian no Guardian's name Guardian's phone Guardian court Guardian case number Power of Attorney yes Power of Attorney no Power of Attorney not sure Health Care Power of Attorney yes Health Care Power of Attorney no Health Care Power of Attorney not sure Living Will yes Living Will no Living Will not sure Last Will and Testament yes Last Will and Testament no Last Will and Testament not sure Revocable Living Trust yes Revocable Living Trust no Revocable Living Trust not sure Irrevocable Trust yes Irrevocable Trust no Irrevocable Trust not sure Representative Payee yes Representative Payee no Representative Payee not sure Marry yes Marry no Marry not sure Vote yes Vote no Vote not sure Hold driver's license yes Hold driver's license no Hold driver's license not sure Execute a Will yes Execute a Will no Execute a Will not sure Execute a contract yes Execute a contract no Execute a contract not sure hold or convey direct property ownership yes hold or convey direct property ownership no hold or convey direct property ownership not sure

Case number Any person dependent on ward yes Any person dependent on ward no Any person providing support yes Any person providing support no Social Security yes Social Security no Social Security not sure IRA yes IRA no IRA not sure 401k yes 401k no 401k not sure Other private employee pension yes Other private employee pension no Other private employee pension not sure Annuity yes Annuity no Annuity not sure PERS yes PERS no PERS not sure STRS yes STRS no STRS not sure Railroad Retirement yes Railroad Retirement no Railroad Retirement not sure Federal Pension yes Federal Pension no Federal Pension not sure Veteran's Benefits yes Veteran's Benefits no Veteran's Benefits not sure Medicaid yes Medicaid no Medicaid not sure Real estate rental yes Real estate rental no Real estate rental not sure Physician name 1 Medical specialty 1 Telephone number 1 Physician name 2 Medical specialty 2 Telephone number 2 Physician name 3 Medical specialty 3 Telephone number 3 Developmental disability Alcohol abuse Dementia Drug or other substance abuse Other infirmities of aging Mental illness Capable of living independently yes Capable of living independently no Home health care services Nursing home facility Assisted living facility Advanced care nursing facility Long-term care insurance yes Long-term care insurance no Long-term care insurance unknown

Case number Attorney typed or printed name Attorney registration number Applicant typed or printed name