Page 1 of 7 of Form A IN THE CIRCUIT COURT, EIGHTEENTH JUDICIAL CIRCUIT IN AND FOR BREVARD COUNTY, FLORIDA Case No.: IN RE: THE GUARDIAN ADVOCACY OF / Name of Person with a Developmental Disability APPLICATION FOR APPOINTMENT A S GUARDIAN ADVOCATE (Form A) Pursuant to 247 393.12, Florida Statutes, the Applicant, (name of Guardian Advocate) submits this Application for Appointment as G uardian Advocate of , the person with a dev elopmental disability, and the following information: (Please provide the following information regarding the Guardian Advocate. Attach additional pages if the space provided is insufficient.) 1. Name of Applicant : 2. Age: 3. Residence Address: 4. Mailing Address: 5. U.S. Citizen ? Yes: No: 6. 7. 8. Home Telephone Number: 9. Work Telephone Number: 10. If currently serving as Gu ardian/ G uardian Advocate for any other Ward, list names of each Ward, court file number(s), circuit court(s) in which case(s) is/are pending and American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 7 of Form A whether applicant is acting as the Limited or Plenary Guardian or Guardian Advocate of the pers on or property or both of each W ard: 11. Does Applicant have any physical disabilities ? Yes: No: If yes, please ty, in any degree, to serve as Guardian A dvocate: 12. Has Applicant ever been treated for the following: a. Mental Condition Yes No b. Alcohol Yes No c. Drugs Yes No d. Other Yes No Nature of condition: above, please state date, time, and location of treatment and name of physician or profession al involved: 13. Has Applicant ever been judicially determined to have committed abuse or neglect against a child as defined by the Florida Statutes ? Yes No 14. 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 247 415.104 and 247 415.1075, Florida Statutes ? Yes No American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 7 of Form A 15. Has Applicant ever been charged with fraud, misrepresentation, or perjury in a judicial or administrative proceeding ? Yes No If yes, please give date and complete details: 16. Has Applicant ever been charged with, ar rested 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 247 943.0583 , Florida Statutes ? Yes No If yes, please provide details including date, type of offe nse, location and final disposition: 17. Has Applicant ever been charged with, arrested for or convicted of any other crimes? Yes No If yes, please provide details including date, type of offense, locati on, and final disposition: 18. Has Applicant ever held a position which required bonding ? Yes No If yes, please describe position, date, amount of bond and name of surety: American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 7 of Form A 19. Has Applicant, in the past, ever served as Guardian/ Guardian Advocate of a person or of ? Yes No If yes, please describe below, including reason for termination of fiduciary position: 20. Has Applicant ever been held in contempt of court or removed as a Guardian/ Guardian Advocate ? Yes No If yes, please describe below: 21. Has Applicant ever filed for bankruptcy ? Yes No If yes, please state date and location of court: 22. 23. , or providing professional, personal, or business services to the person with a developmental disability ? Yes No If yes, please provide details below: American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 7 of Form A 24. Is Applicant employed by a business, corporat ion, or other business entity that is providing professional, personal, or business service to the person with a developmental disability ? Yes No If yes, please furnish details below: 25. Is Applicant a health care provider for the person with a developmental disability? Yes No 26. Educational history of Applicant: Name and Address Degree Date High School College/ University Other American LegalNet, Inc. www.FormsWorkFlow.com Page 6 of 7 of Form A 27. 10 years beginning with the most recent d ates 28. Has Applicant ever been discharged from employment by any employer listed above? Yes No If yes, please explain: Name and Address of the Employer Date Reason for Leaving American LegalNet, Inc. www.FormsWorkFlow.com Page 7 of 7 of Form A 29. Does Applicant possess any special educational qualifications (financial, business, or othe rwise) that uniquely qualify Applicant to be appointed as Guardian A dvo cate? Yes No If yes, pl ease describe below: 30. Has Applicant received instruction and training which covered the legal duties and responsibilities of Guardian/ Guardian Advocate, the rights of an incapacita ted person or Ward, the availability of local resources to aid a Ward, and the preparation of habitual plans and annual Guardian Advocate Reports, including financial accounting for the ? Yes No If so, indicate when and where training 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 , 20 . Signature of Applicant Printed Name of Applicant Address of Applicant Phone Number of Applicant American LegalNet, Inc. www.FormsWorkFlow.com