1 2 3 4 5 6 7 8 9 10 11 IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON IN AND FOR THE COUNTY OF KING In the Guardianship of: _____________________________, 12 ) ) ) ) ) ) Case No.: DECLARATION OF PROPOSED GUARDIAN (Certified) 13 An Alleged Incapacitated Person. 14 1. Personal Information. 15 Name of Proposed Guardian: ______________________________ 16 Certified Professional Guardian #: ______________________________ 17 18 19 (DCLR) Mailing Address of Proposed Guardian: ______________________________ Street Address (if different): ______________________________ City/State/Zip: ______________________________ Telephone Number: __________________ Fax Number: __________________ 20 Email Address: __________________________________________________________ 21 2. Certified Status. The proposed Guardian is a certified professional Guardian in the 22 State of Washington. Attached as Exhibit A to this Declaration is a summary listing the 23 educational programs (pertaining to Guardianships or fiduciary matters) which the proposed 24 Guardian and its employees have attended during the past twelve (12) months. 25 26 DECLARATION OF PROPOSED GUARDIAN (CERTIFIED)- 1 12/2005 GUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 3. Business Form. The form in which the proposed Guardian does business is: 2 [ ] sole proprietor [ ] partnership 3 [ ] corporation ] non-profit corporation 4 4. Identification of Principals of Proposed Guardian. List the name of each member of 5 6 [ [ ] trust company the board of directors, officer, and owner of the business of the proposed Guardian and their titles: ______________________________________________________________. 5. Individual Certified Guardians. List each certified Guardian in the employ of the 7 Guardian who may have responsibilities in this case and the individual certified Guardian 8 who will have supervising responsibility in this case: ____________________________. 9 6. Relationship to Alleged Incapacitated Person. The proposed Guardian has the 10 following relationship with the Alleged Incapacitated Person: 11 _____________________________. 12 7. Guardian’s Organizational Structure. (a) Date the proposed Guardian began doing business: _______________________. 13 14 (b) Allocation of job responsibilities: ______________________________. (Brochures or other printed materials may be attached as an Exhibit in response to this 15 question.) 16 8. Criminal Background Checks. Does the proposed Guardian conduct criminal 17 background checks pursuant to RCW 43.43.832 on all employees or volunteers who will or 18 may have unsupervised access to the Alleged Incapacitated Person? 19 [ 20 9. Criminal and Disciplinary History. Provide the following information for the 21 22 23 24 ] Yes [ ] No proposed Guardian and for each of its principals and employees who are certified professional Guardians. However, do NOT include employees who are neither principals nor certified Guardians: (a) Circumstances leading to removal as a Guardian or as a fiduciary for breach of fiduciary duty or for any other reason: ______________________________. 25 26 DECLARATION OF PROPOSED GUARDIAN (CERTIFIED)- 2 12/2005 GUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 (b) Criminal proceedings for a felony or misdemeanor involving moral turpitude, 2 which resulted in a finding or plea of guilty (attach an explanation as an exhibit explaining 3 why this individual is employed by the proposed Guardian): _________________________. 4 5 6 (c) Civil proceedings in which there was a finding of dishonesty, misappropriation of funds, breach of fiduciary duty, or mistreatment of any person (identify any civil proceedings where there was a settlement, even if such settlement was without specific findings by the Court): _______________________________________. 7 (d) Reported disciplinary proceedings by a disciplinary body or licensing agency 8 that resulted in a finding of misconduct (including proceedings by a professional 9 organization such as a state bar association, a medical disciplinary review board, etc.): 10 _______________________________________________________________________. 11 10. Bond/Insurance. The nature and extent of the proposed Guardian’s insurance coverage 12 13 14 available to provide protection in the event of financial loss or personal harm caused by the negligent or intentional conduct of the proposed Guardian, its employees or agents (list the companies with which insurance or bond is obtained, the policy limit and deductibles) is: __________________________________________________________. 15 11. Compensation and Reimbursement. The proposed Guardian’s compensation schedule 16 is as follows (include the different hourly rates for various services): 17 _______________________________________________________________________. 18 12. Experience. The proposed Guardian’s experience with similar Guardianships (for 19 example, similar amount of assets, the family circumstances of the Alleged Incapacitated 20 21 22 Person, the proximity of the proposed Guardian to the residence of the Alleged Incapacitated Person, and any relevant information) is: _____________________________________. /// 23 /// 24 /// 25 26 DECLARATION OF PROPOSED GUARDIAN (CERTIFIED)- 3 12/2005 GUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com 1 2 3 4 5 6 7 8 9 13. Case Load. The Guardian is currently the Court appointed Guardian for __________ of total individuals in this County and __________ individuals in other Counties. I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. Signed at ________________, Washington, ___________, ____200__. 10 11 12 13 14 Signature Printed Name Address Telephone/Fax Number City, State, Zip Code Email Address 15 16 17 18 19 20 21 22 23 24 25 26 DECLARATION OF PROPOSED GUARDIAN (CERTIFIED)- 4 12/2005 GUARDIANSHIP FORMS American LegalNet, Inc. www.USCourtForms.com