ANNUAL PROFESSIONAL GUARDIANSHIP INVESTIGATION CHECKLIST (including employees of a professional guardian pursuant to §744.3135, Fla.Stat.) This form must be submitted annually by all professional guardians and employees of a professional guardian with a fiduciary obligation to a ward Please make sure to "x" or "check" the appropriate boxes. Guardianship of ___________________________ Reference #__________________________ Name of Guardian/Employee Applicant ___________________________________________________ Any other name used by Applicant/Employee _______________________________________________ Address of Applicant ________________________________________________________________ Street Address City State Zip Guardian Applicant Relationship to Ward ____________________________________________ 1 2 3 4 5 6 7 8 9 10 11 Investigation Checklist Application for Appointment Disclosure Statement for Not for Profit Fingerprint Card Check payable to FDLE for $54.25 Check payable to Clerk of Court for $7.50 (Professional Guardian Processing Fee) Registered with SPGO (Statewide Public Guardianship Office) Blanket Bond Attached is a list of employees who owe a fiduciary responsibility to the ward Employee statement Dept. Children & Families Release Form ( ( ( ( ( ) Attached ) Attached ) Attached ) Attached ) Attached ( ( ( ( ) Not Applicable ) Not Applicable ) Not Applicable ) Not Applicable ( ) Yes ( ) No ( ) Not Applicable ( ) Yes ( ) No ( ) Not Applicable ( ) Yes ( ) No ( ) Not Applicable ( ) Yes ( ) No ( ) Not Applicable ( ) Attached I hereby give my consent for a background check in accordance with Florida Statutes, Chapter 744 to include, but may not be limited to, a check of credit, FDLE, FBI, employment, and Department of Children & Families background. Under penalties of perjury, I declare that I have read the foregoing and the facts alleged are true. ____________________________________ Guardian Applicant Signature _______________________ Date 12/14/11 American LegalNet, Inc. www.FormsWorkFlow.com