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Here is the text we could read:

GUARDIAN'S 
CARE PLAN/REPORT 

Docket No.

Commonwealth of Massachusetts 
The Trial Court 
Probate and Family Court 

In the Interests of:

Division

First Name

Middle Name

Last Name

Incapacitated Person

INSTRUCTIONS TO GUARDIAN:

Fill  this  Report  out  completely,  then  sign  and  date  on  the  last  page.    Attach  separate  sheets  if  needed  to  complete  your 
response to the numbered questions.  File original Report with the Court and serve the Incapacitated Person with a copy in 
hand, or by certified mail, return receipt requested.  Complete the Certificate of Service at the end of this Report.

Age of Incapacitated Person

Your relationship to Incapacitated Person

Date of Decree of Guardianship:

(Check one box)

INITIAL 60 DAY CARE PLAN

ANNUAL REPORT

CURRENT Reporting Period: from

to

(date)

(date)

1.

Describe the Incapacitated Person's current mental, physical, and social condition.

CURRENT CONDITION OF THE INCAPACITATED PERSON

1a.

List the name, address, and type of facility where the Incapacitated Person currently resides or stayed or resided during 
this reporting period. Include dates indicating when each stay or residence began and ended.

LIVING ARRANGEMENTS

Dates of Stay or Residency

Address

If facility, list name and type of facility 
and answer Q1b. below

1b.

Do you consider the current living arrangements or habilitation plan and level of care and treatment to be in the best 
interests of the Incapacitated Person? Explain why or why not. Include your opinion about the adequacy of care and 
services.
LEVEL OF CARE

very good

adequate

good

poor

MPC 821  (8/30/19)    RPTA, RPT60

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2.

SERVICES PROVIDED TO THE INCAPACITATED PERSON

CONDITIONS AND SERVICES

Describe the medical, educational, vocational and other services provided to the Incapacitated Person during this 
reporting period.

3.

ANTIPSYCHOTIC MEDICATION

Is the Incapacitated Person taking and/or receiving antipsychotic medication(s)?

Yes

No

4.

PROTECTION OF INCAPACITATED PERSON

Have any criminal charges or reports of abuse or neglect involving the Incapacitated Person 
been filed with a court or agency since the last report?

Yes

No

If Yes, please explain:  

5.

GUARDIAN'S VISITS AND CONTACT WITH CAREGIVERS

Describe the nature and frequency of your visits with the Incapacitated Person, your contact with caregivers and health 
care providers, and any other activities you undertook on the Incapacitated Person's behalf during this reporting period.

6.

INCAPACITATED PERSON'S PARTICIPATION IN DECISION-MAKING

Describe the extent to which the Incapacitated Person did/did not participate in decision-making about personal and 
health care decisions.

7.

RECOMMENDED CHANGES

FUTURE CARE

Describe the needs of the Incapacitated Person for a continued guardianship. Include any recommended changes and/or 
limitations to the guardianship.

8.

FUTURE ARRANGEMENTS

Describe what residence, services and levels of personal/health care you expect might change for the Incapacitated 
Person during the next 18 months, if any. 

MPC 821  (8/30/19)    RPTA, RPT60

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FINANCES

9a.

Are you a Representative Payee?

Yes

No

9b. Do you hold or receive funds belonging to the Incapacitated Person in your role as Guardian other than as a 

Representative Payee?

Yes   If Yes, answer Question 9c.

No  If No, skip to Question 10.

9c.

Is there a Conservator appointed?

Yes   If Yes, skip to Question 10.

No  If No, answer Question 9d.

9d.

SUMMARY OF FINANCIAL ACTIVITY DURING REPORTING PERIOD

Beginning balance of bank accounts (savings, checking, CDs, money market, etc.)

Plus (+) money received from any source on behalf of the Incapacitated Person (Social 
Security, SSI, pension, disability, interest, etc.)

Less (-) total fees to care providers

Less (-) total monies paid to the Incapacitated Person (personal needs, etc.)

Less (-) total fees paid to the Guardian

Less (-) any other expenses (housing, insurance, maintenance, etc.)

$

+

-

-

-

-

ENDING BALANCE OF BANK ACCOUNTS $

It  is  unlawful  for  a  Guardian  to  co-mingle  personal  funds  with  funds  belonging  to  the  Incapacitated  Person.    All  funds  of  the 
Incapacitated Person MUST be maintained separately and accounted for in this Summary of Financial Activity. 
  
You are required to maintain supporting documentation for all receipts and payments.  The Court or any interested persons may 
request copies of this documentation at any time.

10.

ADD COMMENTS OR CONCERNS THAT YOU HAVE ABOUT THE INCAPACITATED PERSON OR ABOUT THE 
GUARDIANSHIP.

Note:  If you wish to modify or terminate this Guardianship, you must file a separate Petition with the Court.

VERIFICATION AND ACKNOWLEDGEMENT
I swear or affirm that the statements contained in this Report are accurate and complete, to the best of my knowledge and belief.

Signed under the penalties of perjury

(date)

.

Guardian's Signature

Co-Guardian's Signature (if applicable)

Print Name

Print Name

(Address)

(Apt, Unit, No. etc.)

(Address)

(Apt, Unit, No. etc.)

(City/Town)

(State)

(Zip)

(City/Town)

(State)

(Zip)

Primary Phone #: 
E-mail:

Primary Phone #: 
E-mail:

MPC 821  (8/30/19)    RPTA, RPT60

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of

CERTIFICATE OF SERVICE

I certify that on

I provided a copy of this Guardian's Care Plan/Report to the 

(date)

Incapacitated Person 

in hand 

or 

by certified mail, return receipt requested, at the current address as listed

on page 1 of this Report.

Signature of Guardian or Attorney for Guardian

Print Name

(Address)

(Apt, Unit, No. etc.)

(City/Town)

(State)

(Zip)

Primary Phone #: 

BBO No.:

E-mail:

(Do Not Write Below This Line-For Court Use Only)

Reviewed by:
                            Justice, Assistant-Register, Assistant-Judicial Case Manager, Judicial Designee

Date: 

The filed Guardian's Care Plan/Report has been reviewed and 

accepted. No further review needed. 

needs the following further judicial review: 

Further judicial review completed by: 

Date: 

Probate and Family Court Judge

Additional orders: 

MPC 821  (8/30/19)    RPTA, RPT60

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Guardian's Care Plan/Report

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Massachusetts state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.mass.gov (2023-03)
Page(s): 4
Fields(s): 85
Average fields per page: 21
Reading Level: Grade 9
LIST Grouping(s): ES-00-00-00-00, ES-03-00-00-00, FA-00-00-00-00, ES-02-00-00-00.

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Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

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Guardian's Care Plan/Report

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02