THIS FORM MUST BE COMPLETED IN ENGLISH
YUAV TSUM TEB TSAB NTAWV NO UA LUS ASKIV
State of Minnesota
District Court
Xeev Minnesota
Cheeb Tsam Tsev Hais Plaub
Probate Division
Fab Sib Faib Teej Tug
County of ___________________
Judicial District:
Cheeb nroog___________________
Txhooj Hais Plaub:__________________
Court File No.
In Re: Guardianship of
Zauv Cim Rooj Plaub.
Hais Txog: Kev Saib Xyuas rau
Case Type: 14, Guardianship
Hom Plaub Ntug: 14, Kev Saib Xyuas
PERSONAL WELL-BEING REPORT
, Ward
TSAB NTAWV CEEB TOOM TXOG KEV
, Tus Neeg Raug Saib
NOJ QAB HAUS HUV NTAWM TUS
KHEEJ
(Annual Report of Guardian)
(Tsab Ntawv Ceeb Toom Ib Xyoos Twg
Txog Neeg Saib Xyuas)
As required by Minn. Stat. § 524.5-316 the Guardian makes this Annual Report for the reporting
period from
to
.
Raws li txoj cai Minn. Stat. § 524.5-316 tus Neeg Saib Xyuas ua tsab Ntawv Ceeb Toom Ib
Xyoos Ib Zaug no thaum lub caij nyoog ceeb toom txij thaum
mus txog thaum
.
Instructions: Complete all paragraphs. Attach additional sheets if necessary.
Cov Lus Qhia Teb tag nrho cov phab lus. Rhais lwm cov nplooj ntawv ntxiv yog tias tsim nyog.
1.
The current mental, physical and social condition of the Ward is:
(a)
Mental:
(b)
Physical:
(c)
Social:
Zwj ceeb tam sim no txog siab ntsws, lub cev ntaj ntsug thiab kev sib raug zoo ntawm tus
Neeg Raug Saib yog:
(a)
Siab Ntsws:
(b)
Cev Ntaj Ntsug:
(c)
Kev Sib Raug Zoo:
2.
The addresses and types of all living arrangements for the Ward during this reporting
period:
Cov chaw nyob thiab txhua hom kev npaj vaj tse nyob rau tus Neeg Raug Saib thaum lub
caij nyoog ceeb toom no: ___________________________________________________
GAC 11-U State
Hmong
Rev 07/15
www.mncourts.gov/forms
Page 1 of 8
THIS FORM MUST BE COMPLETED IN ENGLISH
YUAV TSUM TEB TSAB NTAWV NO UA LUS ASKIV
State of Minnesota
District Court
Xeev Minnesota
Cheeb Tsam Tsev Hais Plaub
Probate Division
Fab Sib Faib Teej Tug
County of ___________________
Judicial District:
Cheeb nroog___________________
Txhooj Hais Plaub:__________________
Court File No.
In Re: Guardianship of
Zauv Cim Rooj Plaub.
Hais Txog: Kev Saib Xyuas rau
Case Type: 14, Guardianship
Hom Plaub Ntug: 14, Kev Saib Xyuas
PERSONAL WELL-BEING REPORT
, Ward
TSAB NTAWV CEEB TOOM TXOG KEV
, Tus Neeg Raug Saib
NOJ QAB HAUS HUV NTAWM TUS
KHEEJ
(Annual Report of Guardian)
(Tsab Ntawv Ceeb Toom Ib Xyoos Twg
Txog Neeg Saib Xyuas)
As required by Minn. Stat. § 524.5-316 the Guardian makes this Annual Report for the reporting
period from
to
.
Raws li txoj cai Minn. Stat. § 524.5-316 tus Neeg Saib Xyuas ua tsab Ntawv Ceeb Toom Ib
Xyoos Ib Zaug no thaum lub caij nyoog ceeb toom txij thaum
mus txog thaum
.
Instructions: Complete all paragraphs. Attach additional sheets if necessary.
Cov Lus Qhia Teb tag nrho cov phab lus. Rhais lwm cov nplooj ntawv ntxiv yog tias tsim nyog.
1.
The current mental, physical and social condition of the Ward is:
(a)
Mental:
(b)
Physical:
(c)
Social:
Zwj ceeb tam sim no txog siab ntsws, lub cev ntaj ntsug thiab kev sib raug zoo ntawm tus
Neeg Raug Saib yog:
(a)
Siab Ntsws:
(b)
Cev Ntaj Ntsug:
(c)
Kev Sib Raug Zoo:
2.
The addresses and types of all living arrangements for the Ward during this reporting
period:
Cov chaw nyob thiab txhua hom kev npaj vaj tse nyob rau tus Neeg Raug Saib thaum lub
caij nyoog ceeb toom no: ___________________________________________________
GAC 11-U State
Hmong
Rev 07/15
www.mncourts.gov/forms
Page 1 of 8
THIS FORM MUST BE COMPLETED IN ENGLISH
YUAV TSUM TEB TSAB NTAWV NO UA LUS ASKIV
There were no restrictions placed on the Ward’s right to communicate and visitation
3.
with persons of the Ward’s choice.
Tsis muaj kev txwv txiav rau tus Neeg Saib Xyuas txoj cai sib txuas lus thiab sib
xyuas nrog cov tib neeg uas tus Neeg Raug Saib xaiv.
OR
LOS YOG
There were restrictions placed on the Ward’s right to communicate and visitation
with persons of the Ward’s choice and the factual bases for those restrictions are:
Muaj kev txwv txiav rau tus Neeg Raug Saib txoj cai sib txuas lus thiab sib xyuas
nrog cov tib neeg uas tus Neeg Raug Saib xaiv thiab cov ntsiab lus tseeb txog cov kev
txwv txiav ntawd yog: ____________________________________________________
4.
Medical, educational, vocational and other services provided to the Ward in the past year:
Kev kho kab mob kev nkeeg, kev kawm ntawv, kev kawm hauj lwm thiab lwm cov kev
pab cuam uas tau muab rau tus Neeg Raug Saib hauv lub xyoo dhau los:
5.
My opinion of the adequacy of the care given to the Ward in the past year:
Kuv txoj kev xav txog txoj kev zov tu txaus tsim nyog li cas rau tus Neeg Raug Saib hauv
lub xyoo dhau los:
6.
Recommendation regarding continuation of the guardianship or scope of the
guardianship:
Kev pom zoo txog kev txuas ntxiv txoj kev saib xyuas los yog txoj kev saib xyuas txog
qib twg:
7.
I have personally seen the Ward
times in the past year.
Kuv yeej tau pom tus Neeg Raug Saib ______ zaug hauv lub xyoo dhau los.
Pursuant to Minn. Stat. § 524.5-102, subd. 13a, a “professional guardian” or
8.
“professional conservator” means a person acting as guardian or conservator for three or
more individuals not related by blood, adoption, or marriage.
(check boxes below if applicable)
Raws li txoj cai Minn. Stat. § 524.5-102, nqe 13a, tus “kws saib xyuas tshaj lij” los yog
“tus kws ceev xyuas tshaj lij txhais tau tias yog tus tib neeg coj tam li tus neeg saib xyuas
los yog neeg ceev xyuas rau peb tug los yog Raws li txoj cai Minn. Stat. § 524.5-102, nqe
13a, tus “kws saib xyuas tshaj lij” los yog “tus kws ceev xyuas tshaj lij txhais tau tias yog
tus tib neeg coj tam li tus neeg saib xyuas los yog neeg ceev xyuas rau peb tug los yog.
(kos cov kem nram no yog muaj feem xyuam)
GAC 11-U State
Hmong
Rev 07/15
www.mncourts.gov/forms
Page 2 of 8
THIS FORM MUST BE COMPLETED IN ENGLISH
YUAV TSUM TEB TSAB NTAWV NO UA LUS ASKIV
I am a professional guardian according to the above definition.
Kuv yog ib tug neeg saib xyuas tshaj lij raws li cov ntsiab lus txhais saum no.
My answer to the above question reflects a change in my professional status since my
last report to the court for this case.
Kuv cov lus teb rau nqe lus nug saum no qhia tau txog ib yam hloov ntawm kuv qib
tshaj lij txij tom qab kuv tsab ntawv ceeb toom txog rooj plaub no dhau los rau lub
tsev hais plaub.
9.
I have received the following amount of reimbursement for services rendered to the
ward in the past year and this amount was not reimbursed by county contract: $
Kuv txais tau qhov nyiaj them rov qab nram no rau cov kev pab cuam uas tau muab rau
tus neeg raug saib rau lub xyoo dhau los thiab qhov nyiaj no tsis yog them rov qab los ntawm
cheeb nroog kev sib cog lus: $__________
This report must be served annually on the ward and to interested persons of record with the court
within thirty days after the anniversary of the appointment of the guardian. If the personal well-being
report is not filed within 60 days of the required date, the court shall issue an order to show cause.
Tsab ntawv ceeb toom no yuav muab xa ib xyoos ib zaug rau tus neeg raug saib thiab rau cov tib neeg
txuam muaj hauv tsev hais plaub cov ntaub ntawv ua ntej peb caug hnub txwm lub xyoo rau lub sij
hawm xaiv tau tus neeg saib xyuas. Yog tsis ua tsab ntawv ceeb toom kev noj qab haus huv ua ntej 60
hnub txij hnub txwv kom xa, ces lub tsev hais plaub yuav muab lus teev qhia qhov laj thawj.
An interested person may notify the court in writing that the interested person does not wish to receive
copies of annual reports as required by law.
Tus neeg txuam yuav sau tau ntawv faj seeb rau lub tsev hais plaub tias tus neeg txuam tsis xav txais
cov ntawv ceeb toom ib xyoos ib zaug raws li txoj cai txwv.
Dated:
Signature of Guardian
Hnub tim
Neeg Saib Xyuas Kos Npe
Address
(list street/service address only; PO Box not acceptable)
Chaw nyob (qhia kev/lub tsev xa ntawv rau xwb; tsis yuav PO Box)
City, State, Zip
Zos, Xeev, Zauv cim cheeb tsam Zip
Telephone Number
Xov Tooj
E-mail address
Chaw sau ntawv E-mail
GAC 11-U State
Hmong
Rev 07/15
www.mncourts.gov/forms
Page 3 of 8
THIS FORM MUST BE COMPLETED IN ENGLISH
YUAV TSUM TEB TSAB NTAWV NO UA LUS ASKIV
State of Minnesota
District Court
Xeev Minnesota
Cheeb Tsam Tsev Hais Plaub
Probate Division
Fab Sib Faib Teej Tug
County of
Judicial District:
Cheeb nroog
Txhooj Hais Plaub:
Court File No.
Zauv Cim Rooj Plaub.
_____________________
Case Type: 14, Guardianship
In Re: Guardianship of
Hom Plaub Ntug: 14 Kev Saib Xyuas
Hais Txog: Kev Saib Xyuas rau
Annual Notice of Right to Petition for
Restoration to Capacity or Other Relief
Ntawv Faj Seeb Ib Xyoos Twg txog
Txoj Cai Ua Ntawv Thov Kev Rov Kho
,
Kom Muaj Txhij los yog Lwm Txoj
Ward
Kev Tso Dim
,
Tus Neeg Raug Saib
Minn. Stat. §§ 524.5-310(g) and 524.5-316
Txoj cai Minn. Stat. 524.5-310(g) and thiab 524.5-316
To:_______________________________________________________Ward
Rau:
Tus Neeg Raug Saib
You have a right to ask the Court to end or modify the guardianship or for any order that is
in your best interests or for any other appropriate relief, by filing a petition with the Court
explaining why you believe the guardianship should end or be modified.
Koj muaj txoj cai thov lub Tsev Hais Plaub kom xaus los yog hloov txoj kev saib xyuas los
yog lwm yam kev tswj uas yuav zoo dua rau koj los yog thov lwm yam kev tso dim tsim nyog uas
yog ua tsab ntawv thov mus piav qhia seb vim li cas koj thiaj ntseeg tias tsim nyog xaus los yog
hloov txoj kev saib xyuas rau lub Tsev Hais Plaub.
You have a right to object to the Guardian’s change in your place of residence, and you
have a right to ask the Court for a change of residence, by filing a petition with the Court
explaining why the change should or should not be made.
Koj muaj txoj cai tawm tsam tus Neeg Saib Xyuas txoj kev hloov koj qhov chaw nyob,
thiab koj muaj txoj cai thov Tsev Hais Plaub txog kev hloov chaw nyob, uas yog ua ib tsab ntawv
thov mus piav qhia seb vim li cas thiaj tsim nyog hloov los yog tsis tsim nyog hloov rau lub Tsev
Hais Plaub paub.
GAC 11-U State
Hmong
Rev 07/15
www.mncourts.gov/forms
Page 4 of 8
THIS FORM MUST BE COMPLETED IN ENGLISH
YUAV TSUM TEB TSAB NTAWV NO UA LUS ASKIV
You or any interested person on record with the court have a right to dispute any
statement or conclusion contained in the Personal Well-Being Report regarding your condition
by filing a written statement with the Court explaining why you disagree with any statement or
conclusion in the Report.
Koj los yog txhua tus neeg txuam hauv tsev hais plaub cov ntaub ntawv muaj txoj cai sib
cam txog tej nqe lus los yog tej lus txiav txim muaj nyob hauv Tsab Ntawv Ceeb Toom Txog Kev
Noj Qab Haus Huv Ntawm Tus Kheej txog koj qhov zwj ceeb uas yog ua ntawv teev ib nqe lus
piav qhia seb vim li cas koj thiaj tsis pom zoo txog tej nqe lus los yog lus txiav txim muaj nyob rau
hauv Tsab Ntawv Ceeb Toom mus rau lub Tsev Hais Plaub.
If you wish to have a different guardian then you must file a petition for removal of the
guardian, explaining why you believe the present guardian should be removed.
Yog koj xav tau ib tug neeg saib xyuas txawv ces koj yuav tsum ua ib tsab ntawv thov kev
tshem tawm tus neeg saib xyuas, piav qhia seb vim li cas koj thiaj ntseeg kom tshem tawm tus neeg
saib xyuas.
To petition the court you may call the Court Monday through Friday between 8:00 a.m.
and 4:30 p.m. and ask that a form be sent to you, pick up the proper form at the Court, or access
forms from the court’s public website at www.mncourts.gov/forms. The address of the Court is:
and phone number is
.
Xav ua ntawv thov lub tsev hais plaub koj yuav hu tau rau Lub Tsev Hais Plaub Hnub
Monday txog Friday haum 8:00 sawv ntxov txog 4:30 tsaus ntuj thiab thov muab tsab ntawv xa rau
koj, mus nqa tsab ntawv yog hauv lub Tsev Hais Plaub, los yog mus muab tau cov ntawv ntawm lub
tsev hais plaub qhov vas sab qhib rau pej xeem ntawm www.mncourts.gov/forms. Chaw nyob rau
lub Tsev Hais Plaub yog:
thiab tus xov tooj yog.
After a petition is filed the Court will schedule a hearing. You have the right to be
present at that hearing and to have a lawyer represent you. If you cannot afford a lawyer, the
Court will appoint one for you. You can call the Court to request a court appointed attorney.
Tom qab ua tsab ntawv thov tag lawm lub Tsev Hais Plaub yuav teem ib lub rooj sib hais.
Koj muaj txoj cai tshwm rau hauv lub rooj sib hais thiab muaj tau ib tug kws lij choj sawv cev rau
koj. Yog koj them tsis taus ib tug kws lij choj, Tsev Hais Plaub yuav xaiv ib tug rau koj. Koj hu tau
rau lub Tsev Hais Plaub mus thov kom tau tsev hais plaub ib tug kws lij choj.
GAC 11-U State
Hmong
Rev 07/15
www.mncourts.gov/forms
Page 5 of 8
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