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Periodic Personal Care Plan Form. This is a Washington form and can be use in King Local County.
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Tags: Periodic Personal Care Plan, 22A, Washington Local County, King
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
:
Plaintiff(s)
-against-
Calendar No.
:
JUDICIAL SUBPOENA
:
:
:
Defendant(s)
:
......................................................
IN THE SUPERIOR COURT OF WASHINGTON
THE PEOPLE OF THE STATE OF FOR THE COUNTY OF KING
NEW YORK
TO the Guardianship of:
In
)
)
)
)
)
)
______________________________
GREETINGS:
An Incapacitated Person
Case No.:
PERIODIC PERSONAL CARE PLAN
RCW 11.92.043
(PCP)
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
1.
The [ ] Full [ ] Limited Guardian of the Person respectfully submits the following
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Personal Care Plan:
2.
Custody and Residence of Incapacitated Person. The Incapacitated Person was born on
______________________________ subpoena is punishable as ofcontempt of court and willresides liable to
Your failure to comply with this and is now _____ years a age. He/She presently make you
the ___________________________________________(name and address ofand all damages sustained as a
at party on whose behalf this subpoena was issued for a maximum penalty of $50 facility or home).
result of your failure to comply.
The Guardian believes that he/she is receiving satisfactory care, and should continue to reside
Witness, Honorable
Court in
County,
, one of the Justices of the
there.
3.
day of
, 20
Description of Services or Programs Incapacitated Person Receives. The
Incapacitated Person receives the following services or programs:
(Attorney must sign above and type name below)
________________________________________________________________________
4.
Physical and Medical Status and Need of Incapacitated Person. The physical and
Attorney(s)
medical status and needs of the Incapacitated Person are as follows: for
________________________________________________________________________
Office and P.O. Address
Periodic Personal Care Plan - Page 1 of 2
2001 Guardianship Forms
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
:
5.
Index No.
Calendar No.
Mental and Emotional Status of Incapacitated Person. The mental and emotional
:
JUDICIAL SUBPOENA
Plaintiff(s)
status of the Incapacitated Person is as follows:
-against-
:
________________________________________________________________________
6.
:
Description of Functional Abilities of the Incapacitated Person. The following is a
description of the Incapacitated Person’s abilities to perform: and/or assist in the activities of
Defendant(s)
daily living. ___________________________________________________
:
......................................................
7.
Guardian’s Specific Plan for Meeting the Identified and Emerging Personal Care
Needs of the Incapacitated Person. The Guardian’s specific plan for meeting the identified and
THE PEOPLE OF THE STATE OF NEW YORK
emerging personal care needs of the Incapacitated Person is as follows:
TO
________________________________________________________________________
I certify (or declare) under penalty of perjury under the laws of the State of Washington that to the best of
GREETINGS: the statements above are true and correct.
my knowledge
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
SIGNED at __________________, Washington this _______ day of_____________________, 200___ .
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Signature of Guardian
Printed Name of Guardian, WSBA/CPG#
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
Address
Telephone/Fax Number
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
City, State, Zip Code
Witness, Honorable
Court in
County,
Email Address
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
Periodic Personal Care Plan - Page 2 of 2
2001 Guardianship Forms
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
