Page 1 of 4 of Form C 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 PETITION FOR APPOINTMENT AS GUARDIAN ADVOCATE OF THE PERSON AND APPOINTMENT OF STANDBY GUARDIAN ADVOCATE (Form C) Pursuant to 247 393.12(3), Florida Statutes, the Petitioner , (name of Guardian Advocate (s) ) submits this Petition for Appointme nt as Guardian Advocate (s) and Standby Guardian Advocate of , the person with a developmental disability and states as follows: (Please attach additional pages if the space provided is insufficient.) 1. The name of Petitioner (s) is: 2. The age of Petitioner (s) is: 3. The present address of the Petitioner (s) is: 4. 5. The name of the person with a developmental disability is: 6. Th e age of the person with a developmental disability is: 7. The county of residence of the person with a developmental disability is: 8. The present address of the person with a developmental disability is: 9. The primary langua ge spoken by the person with a developmental disability is: American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 of Form C 10. The person has the following developmental disability that manifested before the age of 18 and constitutes substantial handicap that can reasonably be expected to continue indefinite ly: (Place a check next to the disability that applies) ( ) Intellectual D isability ( ) Autism ( ) Cerebral Palsy ( ) Prader - Willi Syndrome ( ) Spina Bifida ( ) Down Syndrome 11. The Petitioner (s) believes that the person with a developmental disabil ity needs a Guardian Advocate. The factual information regarding why a Guardian Advocate (s) is necessary is: I have attached copies of the following listed reports and records documenting the condition and needs of the person with developmental disability: 12. The person lacks capacity to make decisions in the following areas: (Place a check next to which area the person lacks the decision - making capacity) ( ) to mar ry ( ) to vote ( ) to contract ( ) to travel ( ) to have a driver's license ( ) to seek or retain employment ( ) to determine his or her residence ( ) to consent to medical and mental health treatment ( ) to apply for government benefit s ( ) to make decisions about his or her social environment or other social aspects of his or her life including but not limited to education decisions . State the exact areas in which the p erson with developmental disability lacks the capacity to make decisions if not listed above: American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 of Form C 13. The relationship that Petitioner (s) has or had with the provider of health care services, residential services or other services of the person with the developmental disability is: 14. The reasons why the Petitioner (s) believes he or she should be appointed Guardian Advocate (s) are: 15. The Petitioner (s) requests that be appointed Standby Guardian Adv ocate. 16. The proposed Standby Guardian Adv ocate relationship and any previous connections with the person with developmental disabilities are: 17. 18. The reason the propo sed Standby Guardian Advocate should be appointed is WHEREFORE: Petitioner (s) requests to be appointed as Guardian Advocate (s) of the person with the developmental disability . The Petitioner (s) requests the appointment of the proposed Standby Guardian Advocate. The Petitioner (s) is sui juris and otherwise qualified under the laws of the State of Florida to act in such capacity. Under penalties of perjury, I declare that I have read the foregoing, and the facts alleged American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4 of Form C are true to the be st of my knowledge and belief. Signed on this day of , 20 . Signature of Petitioner Printed Name of Petitioner Address of Petitioner Phone Number of Petitioner American LegalNet, Inc. www.FormsWorkFlow.com