CCP N203 A (Rev. 08/16/16) IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, PROBATE DIVISION File No. Estate of Alleged Person with a Disability ORDER APPOINTING TEMPORARY GUARDIAN OF AN ALLEGED PERSON WITH A DISABILITY On the Petition of for the appointment of [printed name of the Petitioner] [printed name of the proposed Temporary Guardian] as Temporary Guardian of the (estate) (person) (estate and person) [printed name of Respondent] of (the "Respondent"), the Court finds that: 1. The proposed temporary guardian is: (a) an Individual (i) Information on Residency (A) who is a resident of Illinois (B) who is a nonresident of Illinois and has complied with §1-11 of the Probate Act of 1975 ("Probate Act") [755 ILCS 5/1-11] by filing with the Court a Designation of Resident Agent to accept service of process, notice or demand required or permitted by law to be served upon the Guardian and (ii) Information on Criminal Background (A) who has not been convicted of a felony. (B) who has been convicted of a felony, but the conviction shall not prevent the appointment because: (1) the appointment is in the Respondent's best interests, after considering the nature and date of the offense and the evidence of the proposed Guardian's rehabilitation, and (2) the offense is not one which, under §11a-5(a)(5) of the Probate Act [755 ILCS 5/11a-5(a)(5)], would prohibit the appointment. and (iii) who is qualified to act as guardian under §11a-5(a) of the Probate Act [755 ILCS 5/11a-5(a)]. (b) a public agency or not-for-profit corporation and is not directly providing residential services to the ward and is qualified to act as guardian under §11a-5(b) of the Probate Act of 1975 [755 ILCS 5/11a-5(b)]. (c) a corporation qualified to accept and execute trusts in Illinois and is qualified to act as guardian under §11a-5(c) of the Probate Act of 1975 [755 ILCS 5/11a-5(c)]. (d) the State Guardian, and the appointment of the State Guardian is appropriate and required because there is no individual suitable and willing to accept the Guardianship appointment. (e) the Cook County Public Guardian who is qualified to act under §13-5 of the Probate Act [755 ILCS 5/13-5]. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 1 of 3 CCP N203 B (Rev. 08/16/16) File No. 2. The Court has jurisdiction to appoint a Temporary Guardian under §§203-204 of the Uniform Adult Guardianship and Protective Proceedings Jurisdiction Act ("UAGPPJA") [755 ILCS 8/203-204] because: (a) Illinois is the Respondent's "home state" as defined in §201(a)(2) of the UAGPPJA. is the Respondent's "home state", but Illinois is a "significant-connection state" as defined in §201(a)(3) of the UAGPPJA and one of the additional requirements specified in §203(2)(A)-(B) of the UAGPPJA applies. (c) Illinois is not the Respondent's "home state" or a "significant-connection state" as defined in §201(a)(2)-(3) of the UAGPPJA, but the "home state" and every "significant-connection state" have declined to exercise jurisdiction because Illinois is the most appropriate forum. (d) Illinois is not the Respondent's "home state" or a "significant-connection state" as defined in §201(a)(2)-(3) of the UAGPPJA, but the circumstances involved constitute an "emergency" as defined in §201(a)(1) of the UAGPPJA, and, as a result, the Court has "special jurisdiction" under §204(a) of the UAGPPJA. 3. In accordance with §11a-4 of the Probate Act, the appointment is necessary for the immediate welfare and protection of the estate or person of the Respondent. 4. The actual harm identified by the Court that necessitates the temporary guardianship is as follows: (b) IT IS ORDERED that: A. [printed name of the proposed Temporary Guardian] be appointed as Temporary Guardian of the B. (estate) (estate and person) of the Respondent. be appointed as Temporary Guardian of the person of the Respondent. C. The powers and duties of the Temporary Guardian be as follows: [printed name of the proposed Temporary Guardian of the person] DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 2 of 3 CCP N203 C (Rev. 08/16/16) File No. D. i. The bond of the Temporary Guardian of the estate and the surety therein, be approved. . ii. The bond of the Temporary Guardian of the person be approved. E. The authority of the Temporary Guardian, if not sooner terminated, shall terminate on ENTERED: Dated ________________________________________ ______________________________________________ Judge Judge's No. [not more than 60 days from the date of this Order] Attorney Number _______________________________ Name ________________________________________ Firm Name ____________________________________ Attorneys for __________________________________ Address _______________________________________ City/State/Zip __________________________________ Telephone _____________________________________ Email ________________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS Page 3 of 3 CCP N203 D (Rev. 08/16/16) File No. INFORMATIONAL PAGE ­ DO NOT ATTACH TO FORM FILED WITH THE COURT This page offers an illustrative list of some common powers and duties of a Temporary Guardian. It is not intended to be an exhaustive list, and many of the listed powers and duties may not be at all appropriate in a particular situation. Examples of common powers and duties often requested for a Temporary Guardian: 1. Investigate, subpoena records, review any and all financial statements and information bearing the Respondent's name at any financial institution, including but not limited to banks, credit unions, brokerage accounts, savings and loan associations, insurance companies and annuity companies. 2. Act as health care surrogate decision maker under the Illinois Health Care Surrogate Act excluding end-of-life decisions. 3. Execute releases and consents on behalf of the Respondent in accordance with the provisions of the Health Insurance Portability and Accountability Act (HIPAA) in order to access the Respondent's medical records and protected health information. 4. Apply for health insurance or governmental benefits, including Medicare Part D. 5. Freeze all accounts bearing the Respondent's name until further Order of Court. 6. Freeze all debit and credit cards held in the Respondent's name. 7. Withdraw up to $ from an account bearing the Respondent's name in order to pay for daily living expenses and nursing care expenses. 8. Place