1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 IN THE CIRCUIT COURT OF STATE OF OREGON FOR THE COUNTY OF MARION Probate Department In the Matter of the Guardianship of: , A Protected Person. ) ) ) ) ) Case No.: DECLARATION IN SUPPORT OF MOTION FOR PAYMENT OF ROOM AND BOARD STATE OF OREGON County of Marion ) ) ss. ) I hereby declare that: 1. I am the Guardian in this matter. 2. The Protected Person lives with me in my dwelling located at: 3. All other people who also live in the dwelling (include name, age and relationship to me): __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION IN SUPPORT OF MOTION FOR PAYMENT OF ROOM AND BOARD - Page 1 of 3 FC 08/25/16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 4. The total per MONTH expenses associated with the HOUSEHOLD are as follows: Rent Mortgage Insurance, property taxes: Utilities (water/sewer, electricity, gas trash): Food for household: Other: Total per month expenses for the household: $ $ $ $ $ $_______________ There is no rent/mortgage. The assessed value is: $ 5. The total per MONTH expenses attributed to the Protected Person are as follows: Rent Mortgage Insurance, property taxes: Utilities (water/sewer, electricity, gas trash): Food for household: Other: $ $ $ $ $ There is no rent/mortgage. The assessed value is: $ Total per month expenses attributed to the protected person is: $__________ 6. The monthly room and board expense I am requesting for housing the Protected Person is: $_____________. I am requesting to deduct the amount in paragraph (6) out of the Protected Person's estate on a monthly basis beginning on :_______________(date) and continuing on the same date each month for as long as the Protected Person is living with me at the above address. 7. I have attached additional documents that support my request for room and board. (For example, this may include documentation from the Social Security Administration or the Veteran's Administration approving the requested room and board amount.) American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION IN SUPPORT OF MOTION FOR PAYMENT OF ROOM AND BOARD - Page 2 of 3 FC 08/25/16 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 8. Additional information I would like the court to consider in making a decision: __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ ________________________________________________________ 9. I make this Declaration in support of my Motion to Allow Payment for Room and Board. I hereby declare that the above statement is true to the best of my knowledge and belief, and that I understand it is made for use as evidence in court and is subject to penalty for perjury. Dated: Signature of Guardian Submitted by: Name Address City, State, Zip Telephone Email Fax Bar No. (if any) I certify this is a true copy: Signature American LegalNet, Inc. www.FormsWorkFlow.com DECLARATION IN SUPPORT OF MOTION FOR PAYMENT OF ROOM AND BOARD - Page 3 of 3 FC 08/25/16