IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON IN AND FOR THE COUNTY OF KING In the Guardianship of: ______________________________, An Alleged Incapacitated Person. 1. Personal Information. Name of Proposed Guardian: _________________________________________ Mailing Address of Proposed Guardian: _________________________________ Street Address (if different): __________________________________________ City/State/Zip: _____________________________________________________ Telephone Number: __________________ Fax Number: __________________ Email Address: ____________________________________________________ If proposed Guardian does not reside in Washington, provide name, address, phone and email address for resident agent: ___________________________________. 2. Non-Professional Status. I am not serving as a Guardian for three or more persons. I acknowledge that before I may serve as a Guardian for three or more persons, I am required to be certified in the State of Washington ) ) ) ) ) ) Case No.: DECLARATION OF PROPOSED GUARDIAN (Non-Certified) (DCLR) DECLARATION OF PROPOSED GUARDIAN (Non-CERTIFIED)- 1 11/2011 REVISED GUARDIANSHIP FORMS American LegalNet, Inc. www.FormsWorkFlow.com 3. Business Form. If appointed, I will serve as a Guardian as an individual person and not serving as an entity or representative of a business entity, such as a trust company or nonprofit corporation. 4. Background and Experience Helpful to Service as Guardian. I have the following background, education and experience, which may be helpful in my service as Guardian: Education, training and experience: ____________________________________ Licenses held: _____________________________________________________ 5. Relationship to Alleged Incapacitated Person. I have the following relationship to the Alleged Incapacitated Person (such as family member, friend, etc.): _______________. 6. Prior History as Fiduciary or Guardian. (a) I have served in a fiduciary capacity (such as an attorney-in-fact pursuant to power of attorney, a trustee, an executor, an administrator, or a Guardian). [ [ ] Yes ] Yes [ [ ] No ] No (b) I have been removed as a fiduciary. If the answer to 6(b) is "Yes," describe the circumstances leading to your removal as a Guardian or as a fiduciary, whether for breach of fiduciary duty or for any other reason: ________________________________________________________________________ 7. Criminal History. RCW 11.88.020(3) expressly provides that no person is qualified to serve as a Guardian if he or she has been "convicted of a felony or of a misdemeanor involving moral turpitude," (a crime involving dishonesty, misappropriation of funds, breach of fiduciary duty, or mistreatment of any person). I have been convicted of such a crime [ ] Yes [ ] No If the answer to the question is "Yes," identify all such convictions and dates: ________________________________________________________________________ 8. Civil Proceedings. Describe any civil proceedings in which there was a finding that you had engaged in dishonesty, misappropriation of funds, breach of fiduciary duty, or mistreatment of any person. Also identify any civil proceeding where there was a DECLARATION OF PROPOSED GUARDIAN (Non-CERTIFIED)- 2 11/2011 REVISED GUARDIANSHIP FORMS American LegalNet, Inc. www.FormsWorkFlow.com settlement, even if such settlement was without specific findings by the Court: _________________________________________________________________________ 9. Disciplinary Proceedings. Describe any recorded disciplinary proceedings against you by any applicable disciplinary body or licensing agency that resulted in a finding of misconduct. This would include any proceedings by a professional organization such as a state bar association, a medical disciplinary review board and the like: ________________________________________________________________________ 10. Ability to Secure Bond. In some cases, it is necessary for the Guardian to secure a bond, which is insurance coverage providing protection to the Alleged Incapacitated Person in the event of financial loss or personal harm caused by the negligent or intentional conduct of the proposed Guardian. Is there any reason (such as bankruptcy or poor credit record) why you would have difficulty obtaining a Guardian's bond. If yes, please explain: ________________________________________________________________________ 11. Compensation and Reimbursement. State whether you intend to request hourly compensation for your services and describe expenses for which you expect to be reimbursed. _____________________________________________________________. I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE OF WASHINGTON THAT THE FOREGOING IS TRUE AND CORRECT. Signed at ________________, Washington, ___________, ____20__. Signature Address City, State, Zip Code Printed Name Telephone/Fax Number Email Address DECLARATION OF PROPOSED GUARDIAN (Non-CERTIFIED)- 3 11/2011 REVISED GUARDIANSHIP FORMS American LegalNet, Inc. www.FormsWorkFlow.com