1 FORM B IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT IN AND FOR PINELLAS COUNTY, FLORIDA PROBATE DIVISION REF #: - -GD - Section 003 IN RE: The GUARDIANSHIP of APPLICATION FOR APPOINTMENT AS GUARDIAN OR GUARDIAN ADVOCATE Pursuant to Sections 744.3125 and 393.12 of the Florida Statutes, the undersigned submits this Application for Appointment as Guardian or Guardian Advocate of and submits the following information (whenever the space provided is insufficient, attach additional pages): 1. Applicant222s Full Name: 2. Specify Applicant222s relationship with the alleged incapacitated person/developmentally Disabled person (or Ward): . 3. Applicant222s Social Security Number: - - 4. Date and place of birth: 5. Residence address: Street City State Zip 6. Mailing address Street City State Zip 7. E-mail address: 8. U.S. citizen? Yes No 9. Employer222s name and address: Name Street City State Zip (If self-employed provide corporate or d/b/a title) Applicant222s position: American LegalNet, Inc. www.FormsWorkFlow.com 2 Professional license number (if any): 10. Please specify if: Unemployed Yes No Retired Yes No Homemaker Yes No 11. Marital status: Married Divorced Single If married, name of spouse: 12. Home telephone number: 13. Length of residence in county where application is filed: 14. Do you serve as Guardian for another ward? Yes No 15. If Yes, provide Ward(s) information below: Ward #1 Name of Ward: Case number: Circuit Court: Guardianship type: Plenary Limited Guardian Advocacy Ward #2 Name of Ward: Case number: Circuit Court: Guardianship type: Plenary Limited Guardian Advocacy 16. Are you a Professional Guardian registered with the Office of Public and Professional Guardians? Yes No If Yes, then attach a complete list of your current wards, location of guardianship and case number to this application. 17. Does the Applicant have any physical disabilities? If yes, describe and state whether they may affect to any extent the Applicant222s ability to serve as a guardian. Has applicant ever been diagnosed with and treated for any of the following: a. Mental illness? Yes No If yes, provide date, location of treatment, any voluntary or involuntary hospitalizations, name of treating physician or professional, and specify if psychotropic medication was prescribed and if Applicant is compliant with the prescribed medication regimen: American LegalNet, Inc. www.FormsWorkFlow.com 3 Date Location Name of treating physician/professional b. Alcohol abuse? Yes No If yes, provide date, location of treatment, and name of treating physician or professional. Date Location Name of treating physician/professional c. Drug abuse? Yes No If yes, provide date, location of treatment, and name of treating physician or professional: Date Location Name of treating physician/professional d. Other? Yes No If yes, describe condition, provide date, location of treatment, and name of treating physician or professional: Date Location Name of treating physician/professional e. Do you own or possess any firearms? Yes No If so, describe your safety procedures and/or precautions: 18. Has Applicant ever been charged with fraud, misrepresentation or perjury in a judicial or administrative proceeding? Yes No If yes, please give date(s) and complete details: 19. Has applicant even been the subject of a confirmed report or judicial determination of abuse, neglect or exploitation of a child, vulnerable adult or elderly person which is prohibited under the provisions of Sections 435.04, 39.01? 984.02 Or 984.03(1), (2), or (37)? Yes No If yes, please give date(s) and complete details: 19 a. Has Applicant ever been arrested for or charged with a Felony? Check yes even if the record American LegalNet, Inc. www.FormsWorkFlow.com 4 of your conviction was expunged, unless it was expunged pursuant to section 943.0583, Florida Statutes Yes No If yes, specify type of offense, location, and final disposition: b. Has Applicant ever been convicted of or entered a plea of guilty or no contest to a felony? Check yes even if the record of your conviction was expunged, unless it was expunged pursuant to section 943.0583, Florida Statutes Yes No If yes, specify type of offense, location, and final disposition: c. Has applicant ever been arrested for or charged with any crime other than a Felony? Check yes even if the record of your conviction was expunged, unless it was expunged pursuant to section 943.0583, Florida Statutes Yes No If yes, specify type of offense, location, and final disposition: d. Has Applicant even been convicted of, entered a plea of guilty or no contest to any crime Other than a felony? Check yes even if the record of your conviction was expunged, unless it was expunged pursuant to section 943.0583, Florida Statutes Yes No If yes, specify type of offense, location, and final disposition: 20. Has Applicant ever held a position which required bonding? Yes No American LegalNet, Inc. www.FormsWorkFlow.com 5 21. Has Applicant ever been removed from a position of Guardian, Agent under a Power of Attorney, Trustee or other fiduciary position for cause? Yes No If yes, describe and specify the reason for termination of fiduciary position: 22. Has Applicant ever been held in contempt of court or removed as a guardian or other fiduciary petition by a court? Yes No If yes, identify the court, case name and case number and specify the reason(s): 23. Has Applicant ever filed for Bankruptcy? Yes No If yes, specify date and location of court: 24. Is Applicant or Applicant222s business, corporation or other business entity a creditor of, or providing professional, personal or business services to the alleged incapacitated person (or Ward)? Yes No If yes, furnish details: 25. Is Applicant employed by a business or corporation that provides professional, personal or business services to the alleged incapacitated person (or Ward)? Yes No If yes, furnish details: American LegalNet, Inc. www.FormsWorkFlow.com 6 26. Is Applicant a licensed health care provider for the alleged incapacitated person (or Ward)? Yes No If yes, furnish details: 27. List Applicant222s educational history (If needed, insert more pages): School #1 Name of School/College/Other: Address: Street City State Zip Date degree conferred: Degree: School #2 Name of School/College/Other: Address: Street City State Zip Date degree conferred: Degree: School #3 Name of School/College/Other: Address: Street City State Zip Date degree conferred: American LegalNet, Inc. www.FormsWorkFlow.com 7 Degree: List Applicant222s employment history for the past five years in reverse chronological order (If needed, insert more pages): Employer #1 Name of Company: Address: Street City State Zip Beginning date: Ending date: Reason for leaving: Employer #2 Name of Company: Address: Street City State Zip Beginning date: Ending date: Reason for leaving: Employer #3 Name of Company: Address: Street City State Zip Beginning date: Ending date: Reason for leaving: American LegalNet, Inc. www.FormsWorkFlow.com 8 28. Has Applicant ever been discharged from employment? Yes No If yes, provide explanation: 29. Has Applicant ever been a member of the armed forces of the U.S.? Yes No If yes, provide the following information: Branch: Release date: Military Serial #: 30. Provide the names, addresses, and telephone numbers of three responsible persons (excluding relatives or spouse) who have been closely associated with Applicant and who have known Applicant for at least five years: Reference #1 Name of referee: Address: Street City State Zip Telephone #: Number of years known: Reference #2 Name of referee: Address: Street City State Zip Telephone #: Number of years known: American LegalNet, Inc. www.FormsWorkFlow.com 1 Reference #3 Name of referee: Address: Street City State Zip Telephone #: Number of years known: 31. Does Applicant have any special educational qualifications (financial, business, or other) that uniquely qualify Applicant to be appointed as guardian? Yes No If yes, describe the qualifications: 32. Has Applicant complied with the guardian education requirements set forth in section 744.3145, Florida Statutes? Yes No If yes, indicate when and wher