Name (and if attorney, Attorney222s Number) Address City, State, Zip Code Telephone Number037 ~ Attorney for ~ Petitioner037 IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAI221I In the Matter of the Guardianship of ) FC-G No. ) ) ORDER APPOINTING GUARDIAN ) WITH ~ LIMITED~UNLIMITED , ) AUTHORITY; EXHIBIT A(Full Legal Name) ) ) Hearing Date: An Incapacitated Person. ) ) Judge: ORDER APPOINTING GUARDIAN WITH ~LIMITED ~UNLIMITED AUTHORITY This matter came on for hearing on the above-mentioned date before the Honorable , Judge of the Family Court, First Circuit. (Full Name of Judge) Following that hearing and after full consideration of all of the evidence, the Court finds that: 1. This Court has jurisdiction and is the proper venue in this matter; 2. The material allegations of the Petition for the Appointment of a Guardian of an Incapacitated Person are true; In accordance with the Americans with Disabilities Act, as amended, and other applicable state and federal laws, if yourequire a reasonable accommodation for a disability, please contact the ADA Coordinator at the First Circuit Family Courtoffice by telephone at 954-8200, fax 954-8308, or via email at adarequest@courts.hawaii.gov at least ten (10) workingdays prior to your hearing or appointment date. Please call the Family Court Service Center at 954-8290 if you have any questions regarding forms or procedures. ORDER APPOINTING GUARDIAN WITH FC Adm 2/27/14 PAGE 1 OF 6 PAGES LIMITED/UNLIMITED AUTHORITY; EXHIBIT A ~ 3. It has been proven by clear and convincing evidence that: a. is an incapacitated person as (Name of Respondent) defined in section 560:5-102 of the Hawai221i Revised Statutes (HRS). b.036 The Incapacitated Person222s identified needs cannot be met by less restrictive means including the use of appropriate and reasonably available technological assistance. 4.036 Appointment of a Guardian is necessary in order to provide continuing care and supervision of said Incapacitated Person; 5.036 The Incapacitated Person was properly served with a notice which complies with the provisions in HRS 247 560:5-309(a); 6. is a fit and proper person and (Name of Proposed Guardian) the best qualified to serve as Guardian; ~003 7. The Guardian shall have unlimited authority because: The Guardian shall have limited authority because: ORDER APPOINTING GUARDIAN WITH FC Adm 2/27/14 PAGE 2 OF 6 PAGES LIMITED/UNLIMITED AUTHORITY; EXHIBIT A NOW, THEREFOR, IT IS HEREBY ORDERED that (Name of Proposed Guardian) be and is hereby appointed Guardian of (Name of Incapacitated Person) to make decisions regarding the Incapacitated Person222s support, care, education, health and welfare, subject to the provisions in HRS 247247 560:5-314, 560:5-315, and 560:5-316. The Guardian shall exercise authorityonly as needed due to the incapacitated person222s limitations and if possible, shall encourage his/her participation in decisions regarding his/her personal affairs, acting on his/her own behalf, and developing or regaining the capacity to manage his/her personal affairs. The Guardian shall consider the expressed desires and personal values of the Incapacitated Person to the extent known to the Guardian. At all times, the Guardian shall act in the Incapacitated Person222s best interests and exercise reasonable care, diligence, and prudence. IT IS HEREBY ORDERED THAT that the Guardian shall have the following duties: 1.036 to become and remain personally acquainted with the Incapacitated Person and maintain sufficient contact with the person to know the person222s capacities, limitations, needs, opportunities, and physical and mental health; 2.036 take resonable care of the Incapacitated Person222s personal effects and bring protective proceedings if necessary to protect the Incapacitated Person222s property; 3.036 expend any monies of the Incapacitated Person, received by the Guardian, for the Incapacitated Person222s current needs for support, care, education, health, and welfare; 4.036 conserve any excess money of the Incapacitated Person for that person222s future needs; provided that if a conservator has been appointed for the Incapacitated Person222s estate, the Guardian shall pay the money to the conservator, at least quarterly, to be conserved for the Incapacitated Person222s future needs; 5.036 immediately notify the court if the Incapacitated Person222s condition has changed so that ORDER APPOINTING GUARDIAN WITH FC Adm 2/27/14 PAGE 3 OF 6 PAGES LIMITED/UNLIMITED AUTHORITY; EXHIBIT A the person is capable of exercising rights previously removed; and 6.036 inform the court of any change in the Incapacitated Person222s custodial dwelling or address; IT IS HEREBY ORDERED THAT THE GUARDIAN SHALL HAVE: ~ limited authority as provided below: ~ unlimited authority037 to make these decisions including, but not limited to, the authority to:037 1.036 apply for and receive money payable to the Incapacitated Person, Guardian, or custodian for the Incapacitated Person222s support under the terms of anystatutorysystem of benefits for insurance or any private contract, devise, trust, conservatorship, or custodianship; 2.036 if consistent with any court orders relating to custody, take custody of the Incapacitated Person and establish that person222s residence, provided that prior court approval is needed if the Incapacitated Person is to live or be moved to a location outside of Hawai221i; 3.036 if there is no conservator, then the Guardian may initiate an action to compel a person to support the Incapacitated Person or pay money for that person222s benefit; 4.036 consent to medical or other care, treatment, or service for the Incapacitated Person; 5.036 consent to the marriage or divorce of the Incapacitated Person; and 6.036 if reasonable under all of the circumstances, delegate to the Incapacitated Person certain responsibilities for decisions affecting that person222s well being. IT IS HEREBY FURTHER ORDERED that the Guardian may not revoke any health care directions as set forth in any medical directive or health care power of attorney, without ORDER APPOINTING GUARDIAN WITH FC Adm 2/27/14 PAGE 4 OF 6 PAGES LIMITED/UNLIMITED AUTHORITY; EXHIBIT A authorization of the Court. However, appointment of this guardianship automatically terminates the authorityof any agent designated in the medical directive or health care power of attorney. IT IS HEREBY FURTHER ORDERED that if the Public Guardian is appointed guardian, the Public Guardian is appointed guardian, the Public Guardian shall have authority to delegate the responsibilities and duties of the Public Guardian to a professional member of the Public Guardian222s staff. IT IS HEREBY FURTHER ORDERED that the Guardian shall provide a written report to the Court of the condition of the Incapacitated Person, account for money and other assets in the Guardian222s possession or control, and such other matters as the Court may direct within thirty days of the filing of this Order and at least annually thereafter by of , and whenever ordered by the Court, and shall give (day) (month) notice, within fourteen days of the filing of this report, together with a copy of the report to the Incapacitated Person ~ and (state name and address): . IT IS HEREBY FURTHER ORDERED that the Guardian shall serve without bond and, with prior court approval, is entitled to reasonable compensation from the Incapacitated Person222s estate for services as Guardian and to reimbursement for room, board, and clothing provided to the Incapacitated Person. See Exhibit A. IT IS HEREBY FURTHER ORDERED that the Guardian shall be discharged upon the death of the Incapacitated Person or upon further order of the Court, but termination does not affect the liability of the Guardian for prior acts, nor the Guardian222s obligation to account for funds and assets of the Incapacitated Person. ORDER APPOINTING GUARDIAN WITH FC Adm 2/27/14 PAGE 5 OF 6 PAGES LIMITED/UNLIMITED AUTHORITY; EXHIBIT A IT IS HEREBY FURTHER ORDERED that, within fourteen days of the filing of this Order, the Guardian shall send or deliver a copy of this Order to the Incapacitated Person and all other persons noticed of the hearing