1 FORM A IN THE CIRCUIT COURT OF THE SIXTH JUDICIAL CIRCUIT FOR PINELLA COUNTY, FLORIDA Probate Division IN RE: GUARDIAN ADVOCACY OF A Person with a Developmental Disability, / CASE NO.: SECTION: PETITION FOR APPOINTMENT OF GUARDIAN/CO-GUARDIAN ADVOCATE(S) Petitioner(s), allege: 1.Petitioner (Full name)222s Residence is and Mailing address isand Email Address is: 2.(If Co-Guardian Advocacy/Co Guardian is sought, list 2nd Petitioner here. If none, write223none224) Petitioner (Full name) 222s Residence is and Mailing address is and Email Address is: 3.Petitioner222s date of birth isand is an adult, age . Petitioner222s relationship to, the person with a developmental disability/alleged incapacitated person (hereinafter the 223Ward224) is . 4.(If Co-Guardian Advocate/Co-Guardian, list 2nd Petitioner here. If none, write 223none224)Petitioner222s date of birth is and is an adult, age . Petitioner222s relationship to the Ward is . American LegalNet, Inc. www.FormsWorkFlow.com 2 ( ( ( ( ( ( 5. (Ward222s full name) is a person with a developmental disability, who was born on , and who is Years of age. The Ward222s primary spoken language is and the last four digits of the Ward222s Social Security number is XXX-XX- The Ward resides in County, Florida, and his/her residential address is: and his/her mailing address is: . 6. The Ward222s next of kin is/are: (include names and addresses of any non-petitioning spouse, parent, and any adult siblings: 7. The Petitioner(s) believe that the Ward is in need of a Guardian Advocate due to his/herdevelopmental disability which manifested itself prior to the age of eighteen (18), specifically (choose one or all that apply): ) intellectual disability (Specify Type if Known: ) cerebral palsy ) autism ) Spina Bifida ( syndrome ) Down syndrome ) Phelan-McDermid syndrome American LegalNet, Inc. www.FormsWorkFlow.com 3 As a result of the above selected condition, the Ward lacks the decision-making ability to do some of the tasks necessary to care for his or her person or property and all medical probability indicates that this condition can reasonably be expected to continue indefinitely. 8.The Petitioner(s) believe(s) a Guardian Advocate is necessary because the Wardlacks the decision-making ability to make informed decisions about the Ward222s own person, specifically the following rights: (check all which apply) Person, Delegable ( ) To determine residence ( ) To consent to medical treatment ( ) To make decisions about environment or other social aspects of life Property, Delegable ( ) To contract ( ) To sue and defend lawsuits ( ) To manage property and income or make any gift or disposition of property ( ) To apply for government benefits Person, Non-Delegable ( ) To marry ( ) To vote ( ) To have a driver's license ( ) To travel Property, Non-delegable ( ) To seek and retain employment 9.Petitioner(s) is/are willing and able to act as Guardian Advocate for the Ward, andshould be appointed as Guardian Advocate because Petitioner(s) is/are the Ward222s (insert relationship to Ward), is willing to serve in that capacity, and is best qualified to act on the Ward222s behalf. American LegalNet, Inc. www.FormsWorkFlow.com 4 10.In accordance with Probate Rule 5.649(a)(7), Petitioner(s) has/have knowledge,information or belief that the Ward HAS/ HAS NOT created an advanced directive, Health Care Surrogate or a durable power of attorney. 11.The Petitioner(s) further state(s) that the Ward is is not indigent. If theward is indigent and having no assets and no income other than public assistance and requests that the Court waive all costs incurred commencing this case and direct the Clerk of the Circuit Court to void all charges related to same. If the Ward is indigent, an Application for Determination of Indigent Status must be filed with this Petition. See Form C 12.Petitioner(s) file(s) with this Court his/her/their Application(s) for Appointment asGuardian Advocate in conjunction with this Petition, pursuant to the applicable Administrative Order of the Court and has completed the Mandatory Guardianship Checklist (Form K) and files the checklist with this petition. Petitioner(s) has/have completed instructions for a Criminal Background Check and has used ORI # FL052104Z to order a copy of the results of the background check to be delivered to the Clerk of the Court. Petitioner(s) has/have completed the DCF Release form and forward the form to the probate division at 501 1st Avenue N., St Petersburg, FL 33701, Suite 222. (The DCF form should NOT be filed with the Clerk). WHEREFORE, The Petitioner(s) request(s) this Court set a hearing to inquire into the Decision-making Ability of the Ward, and should the Court determine it is appropriate to do so, enter an Order appointing the Petitioner(s) as Guardian Advocate(s) for the Ward. The Petitioner(s) further request(s) that this Court allow the Guardian Advocate(s) to file a Case Plan in the form of an Individual Education Plan (IEP), Support Plan, Habilitation Plan, a report from Agency for Persons with Disabilities or a Simplified Guardian Advocate plan, in lieu of the filing of an Initial Plan and Annual Plan, including a physician222s report. The Petitioner(s) further request(s) that this Court allow the Guardian Advocate(s) to file an Affidavit annually stating where the Ward resides and that the funds the Ward receives are used for care maintenance and support of the Ward, if applicable. [NOTHING FURTHER IN THIS PAGE] American LegalNet, Inc. www.FormsWorkFlow.com 5 Under penalties of perjury, I/We 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 Name Address Phone E-mail address (Petitioner) (If co-Guardians, both sign) Executed this day of , 20 . Signature Name Address Phone E-mail address (Co-Petitioner) American LegalNet, Inc. www.FormsWorkFlow.com