Page 1 of 10 Guardianship Plan (Pursuant to F.S. 744.632, this Report with Original Signatures is due within 60 days after the Letters of Guardianship are signed) In the Circuit Court, Sixth Judicial Circuit, Florida Select County: This Report, with original signatures, is due within 60 days after the Letters of Guardianship are signed and remains in effect until it is amended or replaced by the approval of an Annual Guardianship Plan. The ward is living: In a private residence leased or owned by them (house, condo or apartment). In a private residence not leased or owned by them (such as family member). In a facility (Skilled Nursing, Assisted Living, etc). Address and Phone Number where Ward is currently residing: Address: City, State, ZIP: Phone: Mailing Address for Ward (if different from above): Mailing Address: City, State, ZIP: The guardian(s) submit(s) and propose(s) the following initial plan. 1.The guardian states the place and kind of residential setting best suited for the needs of the Ward is: Assisted Living (ALF) Group Home Intermediate Private Residence Skilled Nursing Specialized State Hospital Other (Please Explain Below) Explanation: For Official Use Only: I N R E : G UARDIANSHIP OF : Social Security Number: Case Number: For the period: through Guardianship Inception Date: Date Letters were signed: Indicate if this is a Successor Guardianship: Guardian Name (s) : Attorney Name: American LegalNet, Inc. www.FormsWorkFlow.com Ward Name: Case Number: Page 2 of 10 2. For the plan period, the guardian proposes the following as to the provision of medical services for the Ward: Routine examination by primary care physician Routine examination by dentist Routine examination by Ophthalmologist Routine examination by Specialist 226 area of specialty: Physical Therapy Speech Therapy Occupational Therapy The ward retains the right to make their own decision Other: (Please Explain Below) Explanation: 3. For the plan period, the guardian proposes the following as to the provision of mental health services for the Ward: Routine examination by Psychiatrist/Psychologist Ongoing Treatment Outpatient Ongoing Treatment Inpatient None (Please Explain Below) Other (Please Explain Below) Explanation: 4. For the plan period, the guardian proposes the following as to the provision of personal care of the ward, such as bathing, grooming and feeding: Care Facility Nurses and Aides Family and Friends Other (Please Explain Below) Explanation: 5. For the plan period, the guardian proposes the following to provide for socialization and/or recreational services for the Ward for the plan period. (i.e.: arranging friends and family to visit, encourage participation in facility or day program activities, etc.): Care Facility Nurses and Aides Family and Friends Day Program The Ward retains the right to make their own decision Other (Please Explain Below) Explanation: American LegalNet, Inc. www.FormsWorkFlow.com Ward Name: Case Number: Page 3 of 10 6. The Ward has the following health insurance, accident insurance, private benefits, or governmental benefits to which the Ward is receiving to meet any part of the costs of medical, mental health or related services: Social Security Social Security Disability Income (SSDI) Health Maintenance Organization (HMO) Supplemental Security Income (SSI) Optional State Supplement Institutional Care Program Supplemental Insurance Pension Medicare Medicaid VA Trusts (Please explain the type of Trust and how it covers costs below) Pending Benefits (Please explain why ward is not yet receiving or provide date applied for below) Other (Please Explain Below) Explanation: American LegalNet, Inc. www.FormsWorkFlow.com Ward Name: Case Number: Page 4 of 10 7. The guardian will secure or has secured the following physical and/or mental examinations to determine the Ward222s medical and mental health treatment needs: Data Entry Format: 1st Line input: Provider222s first name, last name, and middle initial 2nd Line input: Street Address 3rd Line input: City, State and Zip Code 4 th Line input : Phone Number Type of Provider Approximate Date of Exam 1 2 3 4 5 6 7 8 9 10 American LegalNet, Inc. www.FormsWorkFlow.com Ward Name: Case Number: Page 5 of 10 8. To assist the Court with review of the initial plan to determine if it is in the best interest of the Ward, please provide the following information: A. Please rate the ability of the Ward to engage in activities of daily living or instrumental activities of daily living (ADL222s): Light Housekeeping Ward needs no help Ward needs some assistance Ward cannot do at all Administration of Medication Ward needs no help Ward needs some assistance Ward cannot do at all Managing Money Ward needs no help Ward needs some assistance Ward cannot do at all Bathing Ward needs no help Ward needs some assistance Ward cannot do at all Prepare Meals Ward needs no help Ward needs some assistance Ward cannot do at all Climbing Stairs Ward needs no help Ward needs some assistance Ward cannot do at all Shopping Ward needs no help Ward needs some assistance Ward cannot do at all Doing Laundry Ward needs no help Ward needs some assistance Ward cannot do at all Toileting Ward needs no help Ward needs some assistance Ward cannot do at all Dressing Ward needs no help Ward needs some assistance Ward cannot do at all Transferring (from wheelchair to chair/bed) Ward needs no help Ward needs some assistance Ward cannot do at all Eating Ward needs no help Ward needs some assistance Ward cannot do at all Walking Mobility Ward needs no help Ward needs some assistance Ward cannot do at all Grooming Ward needs no help Ward needs some assistance Ward cannot do at all Heavy Chores Ward needs no help Ward needs some assistance Ward cannot do at all American LegalNet, Inc. www.FormsWorkFlow.com Ward Name: Case Number: Page 6 of 10 B. The mental disabilities of the Ward are: Alzheimer222s type of dementia Autism Spectrum Disorders Closed Head Injury Dementia Depression Developmental Disabilities Induced by substance abuse Schizophrenia or related disorders Other (Please Explain Below) Explanation: C. The physical disabilities of the Ward are: Mobility Blindness Deafness Diabetic Parkinson222s disease Severe arthritis Other (Please Explain Below) Explanation: D. The assistive devices used by the Ward are (devices currently being used by the ward): Dentures Hearing Aid Wheelchair Walker/Cane Crutches Prosthetics Glasses None Other (Please Explain Below) Explanation: American LegalNet, Inc. www.FormsWorkFlow.com Ward Name: Case Number: Page 7 of 10 NOTE: Per Administrative Order 2009-036, you must file a separate Disaster Plan when filing an initial guardianship plan. The Disaster Plan shall take into account and reflect how each ward222s special needs will be met under the plan in the event the guardian or ward has relocated temporarily due to an emergency situation. An updated Disaster plan will be required if the ward is moved to a new residence. AO 09-36 E. The assistive devices needed by the Ward are (devices needed but ward does not have them): Dentures Hearing Aid Wheelchair Walker/Cane Crutches Prosthetics Glasses None Other (Please Explain Below) Explanation: F. Are the recommendations of the examining committee incorporated into this plan? Yes No Explanation: American LegalNet, Inc. www.FormsWorkFlow.com Ward Name: Case Number: Page 8 of 10 CERTIFICATION AND SIGNATURE OF GUARDIAN(S) (Check all that apply) If the Wards222 ability to exercise rights has changed since the Order Determining Capacity and Appointing Guardian, the guardian must file a Petition to Remove or Petition to Restore Rights (as appropriate.) The Ward was declared totally incapacitated and has not been given a copy of this plan. The Ward is a minor under the age of 14 and has not been given a copy of this plan. The guardian has consulted with the Ward, to the extent reasonable, has honored the Ward222s wishes, and to the maximum extent possible the plan is in accordance with the Wards222 wishes or consistent with the rights retained by the Ward. In exercising his or her powers, the guardian shall recognize any rights retained by the ward {FS 744.