IN THE CIRCUIT COURT OF THE EIGHTH JUDICIAL CIRCUIT IN AND FOR _________________ COUNTY, FLORIDA GUARDIANSHIP DIVISION IN RE: GUARDIAN ADVOCACY OF ____________________________________, (an alleged developmentally disabled person). Case No.:________________________ ______________________________________/ PETITION FOR APPOINTMENT OF GUARDIAN ADVOCATE Petitioner, __________________________________________________, alleges the following: 1. Petitioner's residence is ______________________________________________ _______________________________, County of ______________________and Petitioner's mailing address, if different, is: ______________________________ _________________________________________________________________. 2. 3. Petitioner's date of birth is ______________________________. The name of the person in need of a Guardian Advocate due to a developmental disability is: ______________________________________________________. The nature of this person's developmental disability is: ____________________ _________________________________________________________________. This person's age and date of birth is: __________________________________. The Petitioner's relationship to the person with a developmental disability is: _________________________________________________________________. The Petitioner believes a Guardian Advocate is necessary because: (Attach applicable health care or social service information available that documents the developmental disability). __________________________________________________________________ __________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com __________________________________________________________________ __________________________________________________________________ 4. The specific and exact areas in which the person with a developmental disability lacks the decision-making ability to make informed decisions about his or her care and treatment services or to met the essential requirements for his or her physical health or safety are: (Please check all that apply) ( ) to consent to medical and mental health treatment ( ) to personally apply for government benefits ( ) to seek or retain employment ( ) to decide his or her place of residence ( ) to manage his or her property ( ) to live independently without the assistance of others ( ) other: 5. It is my understanding that as per statute, the creation of a guardian advocacy is appropriate where the person with developmental disabilities lacks the decisionmaking ability to do some, but not all, of the decision-making tasks to care for his or her person or property or if the person has voluntarily petitioned for the appointment of a guardian advocate. § 393.12(2)(a), Fla.Stat. 6. Petitioner asserts the developmentally disabled person is subject to the following legal disabilities and these legal disabilities should be delegated to a guardian advocate for the developmentally disabled person's health and safety: (Please check areas that are being sought for delegation to the guardian advocate) ( ) to contract ( ) to consent to medical, dental, and mental health treatment ( ) to apply for government benefits ( ) to determine the ward's residence ( ) to sue and defend lawsuits ( ) to make decisions about the ward's social environment or other social aspects of his or her life ( ) to manage the ward's property American LegalNet, Inc. www.FormsWorkFlow.com 7. The name and address and relationship to the person with a developmental disability of the proposed guardian advocate is: ___________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _________________________________________________________________, and the relationship of the proposed guardian advocate had or has with a provider of health care services, or other services to the person with a developmental disability is: _______________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ _________________________________________________________________. 8. The person with developmental disabilities receives or may be eligible for the following types of government benefits: __________________________________________________________________ _________________________________________________________________. 9. The person with developmental disabilities has the following property and/or income, other than Social Security benefits: __________________________________________________________________ _________________________________________________________________. 10. The Petitioner shall provide notice and a copy of this petition on the person with developmental disabilities and on his or her next of kin who are known to the petitioner and listed as follows: ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ ____________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com ____________________________________________________________________ ___________________________________ 11. Petitioner requests the appointment of a Standby Guardian Advocate in the event of their untimely death or incapacity and suggests the following person as Standby Guardian Advocate: _________________________________________. WHEREFORE: Petitioner requests _________________________________________________ be appointed as Guardian Advocate of the Person and that ___________________________________________ be appointed as Standby Guardian Advocate of the person. Petitioner states that he/she is a resident of _____________________ County and 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 are true, to the best of my knowledge and belief. Executed this __________ day of _____________________, 20__. ___________________________________ Signature of Petitioner Printed Name: _____________________________________