IN THE CIRCUIT COURT OF THE TWELFTH JUDICIAL CIRCUIT WILL COUNTY, ILLINOIS ­ IN PROBATE IN RE THE ESTATE OF _________________________________________ Name of alleged disabled adult CASE NO: ___________________________ Respondent, A Disabled Adult ORDER APPOINTING TEMPORARY GUARDIAN FOR A DISABLED ADULT On the verified petition of ________________________________________, for adjudication of disability Name of person filing petition and appointment of a temporary and/or permanent guardian, the Court finds that it is necessary for the welfare and protection of the alleged disabled adult to appoint a temporary guardian. IT IS HEREBY ORDERED THAT: A. Name of guardian , is appointed temporary guardian of the person/ Check one estate/ person and estate of ____________________________________________. Name of alleged disabled adult B. The duties and powers of the temporary guardian include the following: # 1 ­ 4: CHECK BOX(ES) ­ NO POWER GRANTED IF BOX(ES) IS NOT CHECKED (1.) Upon finding that residential placement is appropriate under 755 ILCS 5/11a-14.1, the guardian of the person is granted the specific power of residential placement; (2.) The power to act as a surrogate pursuant to the Health Care Surrogate Act; (3.) The power to investigate, safeguard, marshal, and collect the assets of ____________________________________________; Name of alleged disabled adult (4.) The power to expend such sums as is necessary for the benefit of ____________________________________________; Name of alleged disabled adult (5.) The power to execute releases and consents on behalf of the respondent in accordance with the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub.L. No. 104-191, 110 Stat. 1936, to access medical records and information; (6.) All other powers and is granted under 755 ILCS 5/11a-17 and/or Check box if named guardian of person 755 ILCS 5/11a-18 Check box if named guardian of estate of the Probate Act as are necessary for the immediate protection and welfare of ____________________________________________; Name of alleged disabled adult C. Letters of temporary guardianship shall issue to Name of guardian , ANDREA LYNN CHASTEEN, CLERK OF THE CIRCUIT COURT OF WILL COUNTY American LegalNet, Inc. www.FormsWorkFlow.com 56B ­ Part 1 (Revised 12/16) D. The acceptance of office and bond of the temporary guardian is approved: Select box: without surety with surety in the amount of $______________________________. E. The duties and powers of the temporary guardian shall expire within 60 days after the appointment or whenever a permanent guardian is appointed, unless the Court makes findings to extend the temporary guardianship pursuant to § 11a-4(b). F. The Petition for Plenary Guardianship is hereby set for hearing on _________________________________, 20_____ at _________ a.m./p.m. Hearing date and time set by the Court. Dated: __________________________, 20 _______ Enter: _____________________________________ Judge Prepared By: Attorney _______________________________________ Firm __________________________________________ ARDC# _______________________________________ Address ________________________________________ City and Zip ____________________________________ Telephone ______________________________________ ANDREA LYNN CHASTEEN, CLERK OF THE CIRCUIT COURT OF WILL COUNTY American LegalNet, Inc. www.FormsWorkFlow.com 56B ­ Part 2 (Revised 12/16)