IN THE CIRCUIT COURT- 14TH JUDICIAL CIRCUIT Probate and Guardianship Division ­ Elijah Smiley Probate Judge IN RE: THE GUARDIAN ADVOCACY OF _______________________________________ Name of Person with a Developmental Disability (Form C) Case No.: _______________________ PETITION FOR APPOINTMENT AS GUARDIAN ADVOCATE OF THE PERSON ONLY Pursuant to Florida Statute Section 393.12(3), the Petitioner, (name of Guardian Advocate) ___________________________________________ submits this Petition for Appointment as Guardian Advocate of (the person with a developmental disability) ___________________________________________, the Ward and states as follows: 1. The name of Petitioner is: ________________________________________________ 2. The age of Petitioner is: __________________________________________________ 3. The present address of the Petitioner is: ______________________________________ ___________________________________________________________________________ 4. The Petitioner's relationship to the person with a developmental disability is: ___________________________________________________________________________ 5. The name of the person with a developmental disability is: ___________________________________________________________________________ 6. The age of the person with a developmental disability is: ________________________ 7. The county of residence of the person with a developmental disability is: ___________________________________________________________________________ Page 1 of 3 of Form C American LegalNet, Inc. www.FormsWorkFlow.com 8. The present address of the person with a developmental disability is: ___________________________________________________________________________ 9. The primary language spoken by the person with a developmental disability is: ___________________________________________________________________________ 10. The person has the following developmental disability that manifested before the age of 18 and constitutes substantial handicap that can reasonably be expected to continue indefinitely: (Place a check next to the disability that applies) (___) Mental Retardation (___) Autism (___) Cerebral Palsy (___) Prader- Willi Syndrome (___) Spina Bifida 11. The Petitioner believes that the person with a developmental disability needs a Guardian Advocate. The factual information regarding why a Guardian Advocate is necessary is: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 12. I have attached copies of the following listed reports and records documenting the condition and needs of the person with developmental disability: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 13. The person lacks capacity to make decisions in the following areas: (Place a check next to which area the person lacks the decision-making capacity) (___) to marry (___) to vote (___) to contract (___) to travel (___) to have a driver's license (___) to seek or retain employment (___) to determine his or her residence (___) to consent to medical and mental health treatment (___) to personally apply for government benefits (___) to make decisions about his or her social environment or other social aspects of his or her life. State the exact areas in which the Ward lacks the capacity to make decisions if not listed above: _____________________________________________________________________ Page 2 of 3 of Form C American LegalNet, Inc. www.FormsWorkFlow.com ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 14. The relationship that Petitioner has or had with the provider of health care services, residential services or other services of the person with the developmental disability is: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 15. The reasons why the Petitioner believes he or she should be appointed Guardian Advocate are: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ WHEREFORE: Petitioner requests to be appointed as Guardian Advocate of the Ward. The Petitioner 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. Signed on this __________ day of _____________________, 20____. ________________________________________________ Signature of Applicant ________________________________________________ Printed Name of Applicant ________________________________________________ Address of Applicant ________________________________________________ Phone Number of Applicant Page 3 of 3 of Form C American LegalNet, Inc. www.FormsWorkFlow.com