Kansas Guardianship Program

3248 Kimball Avenue, Manhattan, KS 66503-0353
(785)587-8555     1-800-672-0086     www.ksgprog.org

Guardian and/or Conservator Monthly Report

Items in red are required fields

Month: Year: Recruiter:
Guardian (G/C)Name:
Address
E-mail:
Is this a new e-mail address? Yes     No

Ward (W/C)Name:
Provider/Facility/Address:

Address new?   Guardian or Conservator   Ward or Conservatee   New Guardian Phone


Personal Involvement With Ward/Conservatee (W/C):

  1. Number of visits with W/C (If None, please explain)
  2. Approximate number of phone calls and/or written communications with or regarding W/C
  3. Approximate hours per month devoted to guardianship or conservatorship responsibilities

Overview of Advocacy and Protective Services Provided

Check the applicable box. Please Comment

  1. Health Care [Physical/Mental Health]   Remained the same   Improved   Changed   Other
  2. Residential Supports and Services   Meets the individual's needs   Changes Needed   Other
  3. Day Supports and Services   Meets the individual's needs   Changes Needed   Other
  4. Note Special Events or Activities

Financial Information

Not Conservator
  1. Income Benefit Source(s)
    Social Security $
    Veterans Benefits $
    Railroad Benefits $
    Pension $
    Other: $
  2. Who serves as payee?
    Guardian or Conservator
    A Payee Program
    Service Provider
  3. Bank
    Checking Account Balance $ As of
    Savings Account Balance $ As of
  4. Irrevocable Burial Trust $   Special or Supplemental Needs $
Assistance Needed from the KGP.