REQUESTING COURT COUNTY COURT FILE NUMBER PROPOSED PROTECTED PERSON / WARD FIRST NAME MIDDLE NAME LAST NAME PROPOSED CONSERVATOR / GUARDIAN FIRST NAME MIDDLE NAME LAST NAME LIST ANY OTHER NAMES BY WHICH THE PROPOSED CONSERVATOR / GUARDIAN HAS BEEN KNOWN ADDRESS CITY STATE ZIP CODE DATE OF BIRTH mm/dd/yyyy SOCIAL SECURITY NUMBER (OPTIONAL) DRIVERS LICENSE NUMBER (OPTIONAL) STATE THAT ISSUED THE LICENSE RACE/ETHNICITY (OPTIONAL) TELEPHONE NUMBER MF GENDER List professional licenses held from the list included in instructions on page 2. Include board name, license number, and the state that issued the license. List states other than Minnesota where you have resided for full or partial years (including wintering) within the past ten years: _____________________________________________________________________________ If you listed any states above, this form must be accompanied by classifiable fingerprints. See instructions on page 2. I give consent to the Minnesota Department of Human Services to conduct a background study on me as provided in Minnesota Statutes, section 524.5118, and to release the results of the study to the court. SIGNATURE OF PROPOSED CONSERVATOR/GUARDIAN DATE The Court hereby certifies that this is an in forma pauperis proceeding (person only), and qualifies for exemption from fee payment pursuant to Minn. State. Sec. 524.5118, subd. 1 (f) (1). CERTIFIED BY: Page 1 October 2015 American LegalNet, Inc. www.FormsWorkFlow.com GUARDIAN AND CONSERVATOR BACKGROUND STUDY CONSENT / INFORMATION FORM BACKGROUND STUDY REQUIREMENT: Minnesota Statutes, section 524.5118, requires a background study on you for the purpose of assisting the court in determining whether your appointment or continued appointment as a guardian or conservator is in the best interests of the ward or protected person. The background study will include: · A review of criminal records held by the Minnesota Bureau of Criminal Apprehension (BCA) and the Minnesota Department of Human Services (DHS); · A review of records of substantiated maltreatment of vulnerable adults or minors held by DHS; · A search of the the databases listed in 524.5118 subd. 2a (see item 4 below) to determine if you have ever held a professional license directly related to the responsibilities of a professional fiduciary in Minnesota, and any other state in which you have resided in the past ten years; and · A search of the Federal Bureau of Investigation's (FBI) national criminal records repository if you have resided (including wintering) in any state other than Minnesota in the previous ten years; or if the BCA information indicates you are a multistate offender, or your offender status is undetermined or blank. NOTIFICATION OF RIGHTS: You have the following rights: · The right to be informed that the court will request a background study on you for the purpose of determining whether your appointment or continued appointment is in the best interests of the ward or protected person; · The right to be informed of the results of the study and obtain from the court a copy of the results; and · The right to challenge the accuracy and completeness of information provided to the court by DHS or BCA by filing a challenge with the appropriate agency under Minnesota Statutes, section 13.04, subdivision 4. Please note that some challenges may be precluded by Minnesota Statutes, section 256.045, subdivision 3. FEES AND PAYMENTS · The fee for each study is $50 if you have not lived outside of Minnesota in the past ten years. Please note that if the BCA information indicates you are a multistate offender, or your offender status is undetermined or blank, a set of classifiable fingerprints and an additional $30 fee will be required to complete an FBI record search. If this search is required, you will be notified by DHS in writing and the additional payment will be requested at that time. · The fee for each study is $130 if you have resided outside of Minnesota for any period of time during the ten years preceding the background study, and this form must be accompanied by a set of classifiable fingerprints. The $30 fee for processing the fingerprints for the FBI check is included in this fee. · There is no fee for cases approved by the court to proceed in forma pauperis for guardians as provided in Minnesota Statutes, section 524.5118. For conservators of the estate, the fee is paid by the estate. INSTRUCTIONS 1. All information on page 1 of this form is required, unless marked optional. Please type or print legibly. 2. The proposed guardian or conservator must sign and date page 1 of this form. 3. If the proposed guardian or conservator has resided outside of Minnesota in the last ten years (including wintering), this form must be accompanied by a set of classifiable fingerprints. Fingerprint cards can be obtained at the county court administrator's office or by calling the Background Studies Division: 6514316620. 4. If the proposed guardian or conservator has ever held any of the following licenses, include them in the space provided on page 1: Lawyers Responsibility Board; State Board of Accountancy; Board of Social Work, Psychology, Nursing, Medical Practice, Dentistry, or Marriage and Family Therapy; Department of Education, Commerce, or Human Services; Peace Officer Standards and Training (POST) Board. 5. Mail form with appropriate fee(s) or court verification that the case is proceeding in forma pauperis to: Department of Human Services Attn: Guardian Background Studies PO Box 64172 St. Paul, MN 551640242 Page 2 October 2015 American LegalNet, Inc. www.FormsWorkFlow.com