IN THE CIRCUIT COURT FOR THE 17TH JUDICIAL CIRCUIT IN AND FOR BROWARD COUNTY, FLORIDA IN RE: GUARDIANSHIP OF Case Number Judge: _____________________________/ APPLICATION FOR APPOINTMENT AS GUARDIAN Pursuant to §744.3125, Fla. Stat., the undersigned submits this Application for Appointment as Guardian of ________________________________ (the Ward) and submits the following information (whenever the space is insufficient, attach additional pages): 1. Name: ______________________________________________________________ 2. Social Security Number:________________________________________________ 3. Date and Place of Birth: ________________________________________________ 4. Residence address: ___________________________________________________ ______________________________________________________________________ 5. Mailing address: ______________________________________________________ ______________________________________________________________________ 6. U.S. Citizen? Yes ________ No________ 7. Employer’s name and address: _________________________________________ ______________________________________________________________________ Applicant’s position: ___________________________________________________ 8. Marital status and name of spouse, if any: ________________________________ 9. Home telephone number:______________________________________________ 10. Length of residence in county wherein application is filed __________________ 11. If currently serving as guardian for any other ward, list names of each ward, 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: (attach additional pages if necessary): __________________________________ Effective October 1, 2005 1 American LegalNet, Inc. www.FormsWorkflow.com 12. Does applicant have any physical disabilities?:_____________________________ If yes, please describe and state whether such disability may affect applicant’s ability, in any degree, to serve as guardian _______________________________ 13. 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: _______________________________________________ If yes was answered to any of the above, please state date, time, location of treatment and name of physician or professional involved __________________ 14. Has applicant ever been judicially determined to have committed abuse or neglect against a child as defined by Florida Statutes? Yes _____ No_____ 15. Has applicant ever been the subject of a confirmed report of abuse, neglect, or exploitation which has been contested or upheld pursuant to the provisions of Sections 415.104 and 415.1075, Florida Statutes? Yes ________ No________ 16. Has applicant ever been charged with fraud, misrepresentation or perjury in a judicial or administrative proceeding? Yes ________ No________ 17. Has applicant ever been: a. Charged with a felony? Yes ________ No________ b. Arrested for a felony? Yes ________ No________ c. Convicted of a felony? Yes ________ No________ d. Entered a plea of guilty or no contest to a felony? Yes ________ No________ If yes, to any of the above, please furnish details, including type of offense, location and final disposition:_________________________________________________ Effective October 1, 2005 2 American LegalNet, Inc. www.FormsWorkflow.com 18. Has applicant ever been: a. Charged with any crime other than a felony? Yes ________ No________ b. Arrested for any crime other than a felony? Yes ________ No________ c. Convicted of any crime other than a felony? Yes ________ No________ d. Entered a plea of guilty or no contest to a crime other than a felony? Yes ________ No________ If yes, to any of the above, please furnish details, including type of offense, location and final disposition: ____________________________________________ 19. Has applicant ever held a position which required bonding? Yes ___ No___ 20. Has applicant, in the past, ever served as guardian of a person or of a person’s property? Yes ________ No________ If yes, please describe below, including reason for termination of fiduciary position:______________________________________________________________ 21. Has applicant ever been held in contempt of court or removed as a guardian? Yes ________ No________ If yes, please describe below: __________________________________________ 22. Has applicant ever filed for bankruptcy? Yes ________ No________ If yes, please state date and location of court: ____________________________ 23. What is applicant’s relationship to the alleged incapacitated person (or ward, if renewal application)? _______________________________________________ 24. Is applicant, or applicant's business or corporation or other business entity a creditor of or providing professional, personal or business services to the incapacitated person? Yes ________ No________ If yes, please furnish details: ___________________________________________ 25. Is applicant employed by a business, corporation or other business entity which is providing professional, personal or business services to the incapacitated person? Effective October 1, 2005 3 American LegalNet, Inc. www.FormsWorkflow.com Yes ________ No________ If yes, please furnish details: ____________________________________________ 26. Is applicant a health care provider for the alleged incapacitated person? Yes ________ No________ 27. Educational history of applicant Name and Address Degree Date High School _______________________________________________________________ College Other 28. _______________________________________________________________ _______________________________________________________________ List applicant’s employment experience for the past 10 years beginning with the most recent date Name and Address Date Reason Leaving for ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 29. Has applicant ever been discharged from employment? Yes _____ No_____ If yes, please explain: _________________________________________________ 30. Has applicant ever been a member of the armed forces of the U.S.? Yes ____ No_____ If yes, what branch, dates and military serial number: _____________________ Effective October 1, 2005 4 American LegalNet, Inc. www.FormsWorkflow.com 31. PERSONAL REFERENCES. Please give the names, addresses and telephone numbers of three (3) responsible persons who have been closely associated with applicant and who have known applicant for five (5) years or more, not including relatives or spouse Name and address Telephone Number ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 32. Does applicant possess any special educational qualifications (financial, business, or otherwise) that uniquely qualifies applicant to be appointed as guardian? Yes ________ No________ If yes, please describe: ________________________________________________ 33. Has applicant received instruction and training which covered the legal duties and responsibilities of a guardian, the rights of an incapacitated person, the availability of local resources to aid a ward, and the preparation of habilitation plans and annual guardianship reports, including financial accounting for the ward’s property? Yes ________ No________ If yes, indicate when and where training was received. If the instruction and training was the professional guardianship class required by '744.1085 then please also state whether you have taken the professional guardian competency examination. If you have taken the professional guardian competency examination, please attach proof that you passed the examination. Proof of passing the professional guardian competency examination is required only for initial applications._______________________ _____________________________________________________________________ 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 ____________________________ , 20_____ ____________________________________ Applicant Effective October 1, 2005 5 American LegalNet, Inc. www.FormsWorkflow.com