IN THE CIRCUIT COURT OF THE SEVENTEENTH JUDICIAL CIRCUIT IN AND FOR BROWARD COUNTY, FLORIDA IN RE: NONPROFIT CORPORATION (Insert Name) ______________________________________/ DISCLOSURE STATEMENT Pursuant to ' 744.3125, Fla. Stat., the undersigned submits this Disclosure Statement for the quarter beginning ____________________ and ending _________________________ and submits the following information (whenever the space provided is insufficient, attach additional pages): 1. Name of Nonprofit Corporate Guardian__________________________________ 2. Nonprofit Corporate Guardian’s Address_________________________________ ______________________________________________________________________ 3. This Nonprofit Corporation is organized under Florida law for (please circle one) Religious or Charitable Purposes. 4. Nonprofit Corporate Guardian’s phone number___________________________ 5. Professional Guardian’s name and social security number___________________ ______________________________________________________________________ 6. Has the Nonprofit Corporation's Professional Guardian ever been treated for the following? If yes, please indicate which professional guardian. a. Mental condition? Yes ________ No________ b. Alcohol? Yes ________ No________ c. Drugs? Yes ________ No________ d. Other? Yes ________ No________ Nature of Condition________________________________________________ Effective 10/1/2005 1 American LegalNet, Inc. www.FormsWorkflow.com If yes was answered to any of the above, please state date, time, location of treatment and name of physician or professional involved__________________ _____________________________________________________________________ 7. Has the Nonprofit Corporation’s Professional Guardian listed ever been judicially determined to have committed abuse or neglect against a child as defined by Florida Statutes? Yes ___ No ____ If yes, please indicate which professional guardian_________________________ 8. Has the Nonprofit Corporation’s Professional Guardian 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________ 9. Has the Nonprofit Corporation’s Professional Guardian ever been charged with fraud, misrepresentation or perjury in a judicial or administrative proceeding? Yes ________ No________ 10. Has the Nonprofit Corporation’s Professional Guardian ever been a. Charged with a felony? Yes ________ No________ b. Arrested for a felony? Yes ________ No________ c. Convicted of 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__________________________________________ 11. Has the Nonprofit Corporation’s Professional Guardian 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________ Effective 10/1/2005 2 American LegalNet, Inc. www.FormsWorkflow.com d. Entered a plea of guilty or no contest to a crime other than a felony? 12. Yes ________ No________ Has the nonprofit corporation's professional guardian ever been denied bond or had a bond forfeited? Yes ________ No________ If yes, please provide details, including the name of surety and the date(s)____ ______________________________________________________________________ 13. Has the nonprofit corporation's professional guardian ever been held in contempt of court or removed as guardian? Yes ________ No________ If yes, please describe __________________________________________________ 14. Has the nonprofit corporation's professional guardian ever filed bankruptcy? Yes ________ No________ If yes, please state date and location of court______________________________ 15. Has the nonprofit corporation's professional guardian, or applicant’s business, corporation or other business entity ever been a creditor of, or providing professional or business services to any incapacitated person prior to appointment as guardian? Yes ________ No________ If yes, please furnish details____________________________________________ 16. Has the nonprofit corporation's professional guardian ever been a health care provider for any alleged incapacitated person prior to appointment as guardian? Yes ________ No________ 17. Educational history of the nonprofit corporation's professional guardian Name and Address Degree Date High School ________________________________________________________ College ________________________________________________________ Other Effective 10/1/2005 ________________________________________________________ 3 American LegalNet, Inc. www.FormsWorkflow.com 18. Has the nonprofit corporation's professional guardian received the minimum of 40 hours of instruction and training as required by Florida Statutes? Yes ________ No________ 19. Please list the nonprofit corporation’s professional guardian's continuing education as required by Florida Statutes Class Credit Hours Date ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 20. List the names of all wards for whom the corporation is acting as guardian, the court file number and circuit court in which each case is pending and a statement as to whether the corporation is acting as limited or plenary guardian of the person or property or both, of each ward. ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ I hereby certify that the nonprofit corporation filing this disclosure statement is a nonprofit corporation organized for religious or charitable purposes under Florida law. 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. ________________________ Date Applicant’s signature Effective 10/1/2005 4 American LegalNet, Inc. www.FormsWorkflow.com