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Page 1 of 2 Annual Report on Minor 02/13/2013 ELEVENTH JUDICIAL CIRCUIT COURT McLEAN COUNTY, IL In the Matter of the Estate of: Case Number: , a minor. ANNUAL REPORT ON MINOR NOW comes the Guardian of the person named in the caption hereto, under penalties of perjury as provided under Section 1-109 of the Code of Civil Procedure, stating: 1. An Order was entered on appointing the undersigned Guardian of the person of the above captioned minor. 2. The last Annual Report was made to the Court on 3. The minor’s current mental, physical, and social condition is: 4. The minor’s present living arrangement, a description and address of every residence where the minor lived during the reporting period and length of stay at each place is: 5. A summary of the medical, educational, vocational, and other professional services given the minor is: ---PAGE BREAK--- Page 2 of 2 Annual Report on Minor 02/13/2013 6. Other information which may be useful to the Court is: CERTIFICATION Under penalties of perjury as provided by law pursuant to Section 1-109 of the Code of Civil Procedure, the undersigned certifies that the statements set forth in this instrument are true and correct. Date Signature Print Name Any person who makes a false statement, material to the issue or point in questions, which he does not believe to be true, in any document certified by such person in accordance with 735 ILCS 5/1-109 shall be guilty of a Class 3 felony punishable by two to five years imprisonment and/or a $25,000 fine.