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Form 1. Annual Report of Guardian for a Minor Child [Number assigned by publisher]

Arizona Revised Statutes AnnotatedLocal Rules of Practice Superior Court

Arizona Revised Statutes Annotated
Local Rules of Practice Superior Court (Refs & Annos)
Pima County (Refs & Annos)
Forms
17C A.R.S. Super.Ct.Local Prac.Rules, Pima County, Form 1
Form 1. Annual Report of Guardian for a Minor Child [Number assigned by publisher]
Attorney's Name:
______________________________
Computer Number:
______________________________
Party Name:
______________________________
Street Address:
______________________________
City, State, and Zip:
______________________________
Telephone Number:
______________________________
ARIZONA SUPERIOR COURT IN PIMA COUNTY
IN THE MATTER OF:
)
)
Case Number:
Name: (from birth certificate)
)
)
 
)
ANNUAL REPORT OF
Date of birth:
)
GUARDIAN FOR A MINOR
 
)
CHILD
)
A MINOR
)
)
WARNING--READ AND SIGN
By filing this Report with the court, you are stating under penalty of perjury that the statements contained in it are true to the best of your knowledge. If you state facts in this Report that you know to be false, you may be subject to serious penalties. Such penalties may include, but are not limited to, criminal prosecution for perjury, and/or a finding of criminal contempt. Perjury is a felony for which a term of four years in prison may be imposed. A person may be incarcerated for up to four months if found to be in criminal contempt of court.
I, __________, have read the above warning,
Signed:
 
Dated:
 
I, ____________________ declare under oath and under penalty of perjury:
1.
Describe the type of home or facility where the minor resides:
Empty Checkbox
Private Residence
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Group Home (if so, describe and list the name of the home)
 
 
What is the name of the person in charge of the residence or home?
 
What is the address of the residence or home?
 
Who is the minor's primary caregiver?
 
2.
How many times have you seen the minor in the last twelve months?
 
What date did you last see the minor? ___/___/_____
3.
List any major changes in the minor's development that you have observed in the last year:
 
 
 
 
4.
What is the name of the school the minor is currently attending?
 
 
Describe the progress being made by the minor in school:
 
 
5.
List the name, address and phone number of the minor's physician:
Name:
______________________________
Address:
______________________________
______________________________
Telephone:
(___)__________________________
6.
What date was the minor last seen by a physician? ___/___/_____
7.
I have attached a copy of the following document from the minor's physician:
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Minor's physician's report to the guardian
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Statement containing the physician's observations on the minor's physical and mental health
8.
List any major changes in the minor's physical or mental condition observed by you in the last year:
 
 
 
9.
Answer the following questions only if the minor is a disabled or incapacitated person:
Will the minor reach the age of
majority (18) during the coming year?
Yes Empty CheckboxNo Empty Checkbox
Do you believe that, because the minor
is incapacitated, the guardianship should
be continued after the minor becomes
an adult?
Yes Empty CheckboxNo Empty Checkbox
10.
What services are being provided to the minor by a government agency? (Include any Social Security benefits paid on behalf of the minor):
 
 
 
List the name and title of the individual responsible for the minor's affairs with that agency:
 
11.
List all persons, including any minors, who reside with the minor. If a minor residing in the household is also the subject of a guardianship, list the case number of the guardianship:
Name:
Relationship: to
minor
Case number (if
applicable)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
12.
Has any person who resides with the minor ever been convicted of a felony, or adjudicated as a delinquent child? If so, explain. Provide the State and County where the offense was committed and the case number for the conviction. Provide the State, County, and Court where the adjudication of delinquency was made.
 
 
 
 
13.
Have any proceedings for adoption, custody, or dependency of this child been commenced within the preceding 12 months? If proceedings have been commenced, the guardian must provide the case number of the proceedings to this court.
 
 
 
14.
Is the minor enrolled in a health insurance plan or an equivalent program (such as AHCCCS) run by the state?
 
 
15.
What efforts have you made to obtain child support from the child's parents, either in person or through a state agency? If a Title IV(D) case has been filed by the Attorney General, provide the case number of that case.
 
 
 
16.
A copy of this report must be mailed to the following people at least nineteen (19) days before the hearing date. By providing the information below, you are swearing, under penalty of perjury, that the Annual Report of Guardian for a Minor was mailed to the following persons:
Person
Name
Address
Date of Mailing or Delivery
The minor if over
the age of 14
The minor's
conservator
The court-
appointed attorney
for the minor (if
one has been
appointed)
The minor's parent
or parents
Any other
interested person
who has filed a
demand for notice
with the court
I, the undersigned, swear or affirm that the answers set forth above are true and correct to the best of my knowledge and belief, subject to the penalties of making a false affidavit or declaration.
DATED: _______________
 
Guardian's name
Mail original report to:
Probate Clerk
Arizona Superior Court in Pima County
110 W. Congress St., Tucson, AZ 85701

Credits

Added and effective on emergency basis Sept. 28, 2005. Adopted in final form Jan. 20, 2006.
17C A. R. S. Super. Ct. Local Prac. Rules, Pima County, Form 1, AZ ST PIMA SUPER CT Form 1
State Court Rules are current with amendments received through March 1, 2024. The Code of Judicial Administration is current with amendments received through February 15, 2024.
End of Document