IN THE CIRCUIT COURT FOR FLORIDA IN RE: GUARDIANSHIP OF COUNTY, PROBATE DIVISION File No. Division APPLICATION FOR APPOINTMENT AS GUARDIAN Pursuant to Florida Statutes Section 744.3125, the undersigned submits this Application for Appointment as Guardian of (the Ward) and submits the following information (whenever the space provided is insufficient, attach additional pages): 1. 2. 3. 4. 5. 6. Name: Age: Residence address: : Mailing address: U.S. citizen? Yes No Employer's name and address: Applicant's position: 7. Home telephone number: Work telephone number: 8. If currently serving as guardian for any other ward, list names of each adult ward and the initials of each ward who is a minor, court file number(s), circuit court(s) in which the case(s) is/are pending and whether applicant is acting as the limited or plenary guardian of the person or property or both: Bar Form No. G-3.055 - 1 of 5 © Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com 9. Does applicant have any physical disabilities? Yes No If yes, please describe and state whether such disability may affect applicant's ability, in any degree, to serve as guardian: . 10. Has applicant ever been treated for the following: a. b. c. d. Mental condition? Alcohol? Drugs? Other? Yes Yes Yes Yes No No No No Nature of condition and summary of treatment: . 11. Has applicant ever been judicially determined to have committed abuse, abandonment or No neglect against a child as defined by the Florida Statutes? Yes 12. Has applicant ever been the subject of a confirmed report of abuse, neglect, or exploitation which has been uncontested or upheld pursuant to the provisions of Section 415.104 Florida Statutes? Yes 13. No ______ Has applicant ever been charged with fraud, misrepresentation or perjury in a judicial No If yes, please give date and complete details: or administrative proceeding? Yes . 14. Has applicant ever been arrested for or convicted of a felony, even if the record of such arrest or conviction has been expunged, unless the expunction was ordered pursuant to Florida Statutes Section 943.0583? Yes final disposition: No If yes, please furnish details including date, type of offense, location and . Bar Form No. G-3.055 - 2 of 5 © Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com 15. Yes No Has applicant ever been charged with, arrested for or convicted of any other crimes? If yes, please furnish details including date, type of offense, location and final disposition: . 16. Has applicant ever held a position which required bonding? Yes No If yes, please describe position, date, amount of bond and name of surety: . 17. Yes No Has applicant ever served as guardian of a person or of a person's property? If yes, please describe below, including reason for termination of fiduciary position: . 18. Has applicant ever been held in contempt of court or removed as guardian? Yes No If yes, please describe below: . 19. Has applicant ever filed for bankruptcy? Yes No If yes, please state date and location of court: . 20. What is applicant's relationship to the alleged incapacitated person? . 21. Is applicant, or applicant's corporation or other business entity a creditor of, or providing No If yes, please professional, personal or business services to the incapacitated person? Yes furnish details: . Bar Form No. G-3.055 - 3 of 5 © Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com 22. Is applicant employed by a corporation or other entity which is providing professional, Yes No If yes, please furnish personal or business services to the incapacitated person? details: . 23. Is applicant a health care provider for the alleged incapacitated person? Yes 24. No Educational history of applicant: Name and address Degree Date High school: College: Other: 25. recent date: Name and address Date Reason for leaving List applicant's employment experience for the past ten (10) years beginning with the most 26. Was applicant discharged from employment by any employer listed above? Yes No If yes, please explain: 27. Does applicant possess any special educational qualifications (financial, business or No If yes, please describe otherwise) that qualify applicant to be appointed guardian? Yes below: Bar Form No. G-3.055 - 4 of 5 © Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com 28. Has applicant received instruction and training which covered the legal duties and No If so, please describe and indicate when and where training responsibilities of a guardian? Yes was received. Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged are true, to the best of my knowledge and belief. Signed on this day of , . Applicant [Print or Type Names Under All Signature Lines] Bar Form No. G-3.055 - 5 of 5 © Florida Lawyers Support Services, Inc. January 1, 2017 American LegalNet, Inc. www.FormsWorkFlow.com