WRITTEN STATEMENT OF BACKGROUND AND QUALIFICATIONS FOR PIERCE COUNTY SUPERIOR COURT G.A.L. REGISTRY UNDER RCW 11.88.090 I, _______________________________, state the following as an outline of my background and qualifications to be eligible for the Pierce County Superior Court Guardian Ad Litem registry under RCW 11.88.090(3): A. Level of formal education and year degree(s) obtained: B. Training related to Guardian ad Litem’s duties: C. Number of years’ experience as a Guardian ad Litem under RCW 11.88.090: 1. List year and county(ies) first served on a certified RCW 11.88.090 registry. 2. List each year and the county (ies) in which you have been appointed to serve on a RCW 11.88.090 registry. D. Number of appointments you have received as a Guardian ad Litem and the county or counties of appointment during the last year, 1/1/04 to 12/31/04 (if not a new applicant): E. Percentage of your total case load that RCW 11.88 Guardian ad Litem work represents overall: F. Criminal history, as defined in RCW 9.94A.030: Completed Washington State Patrol Conviction Criminal History Record must be received by the Court. Date Report Received _______________ G. Have you ever been accused of, or been a victim of domestic violence or an anti-harassment action? Yes _____ No ______. If yes, please explain. RCW 11.88 Written Statement of Background and Qualifications Page 1 Revised 1/31/05 American LegalNet, Inc. www.USCourtForms.com H. Evidence of my knowledge, training, and experience, in the following areas, pursuant to RCW 11.88.090 (3) (b) (I). You must complete in full the information requested below, in the space provided, in addition to attaching your resume or vitae. However, answers that only refer to a resume or vitae are not acceptable so do NOT just attach these documents: 1) The needs of impaired elderly: 2) The needs of persons with physical disabilities: 3) The needs of persons with mental illness: 4) The needs of persons with developmental disabilities: 5) Other areas relevant to the needs of incapacitated persons: 6) Legal procedure: 7) The number of times I have been removed for failure to perform duties as Guardian ad Litem. For each removal, give a brief explanation with the case name, cause number and county, and attach all relevant documents from the court file. 8) Please list all other trainings you have attended, the month/year attended and the materials covered in each training you attended. I also certify the following: I. I have successfully completed the Guardian ad Litem training required by the Pierce County Superior Court and under the laws of the State of Washington. AGREE ______ DISAGREE______ J. My normal hourly rate is $_________. My hourly rate to serve as Guardian ad Litem in guardianships is $_________ (unless County pay). K. I am presently not serving, nor have I recently applied to serve, as a Judge or Commissioner pro tempore in Pierce County Superior Court. AGREE ______ DISAGREE______ L. I have no criminal history or license suspension or revocation. AGREE ______ DISAGREE______ RCW 11.88 Written Statement of Background and Qualifications Page 2 Revised 1/31/05 American LegalNet, Inc. www.USCourtForms.com M. I am not the subject of any pending investigation or action by a government agency, professional organization or one that would result in either a criminal conviction or a license revocation or suspension. AGREE ______ DISAGREE______ If you disagree, please explain. N. I will not accept any appointment involving a conflict of interest, and in the event I discover a conflict in the course of an appointment/investigation, I will immediately advise the parties, counsel, and court. AGREE ______ DISAGREE______ O. I have read, signed, returned and agreed to be governed by the Pierce County Superior Court RCW 11.88 G.A.L. Code of Conduct as set out in the Pierce County Superior Court Administrative Policy #4. AGREE ______ DISAGREE______ P. I have read and understand the applicability to me of the Pierce County Superior Court Administrative Policy #3 for the RCW 11.88 G.A.L. Registry for Guardianships, as amended 9/1/04. AGREE ______ DISAGREE______ I further certify that in addition to the above, I have thoroughly studied the provisions and requirements of Chapters 11.88 and 11.92 RCW, and believe I am fully qualified to be appointed as a Guardian ad Litem in Pierce County, Washington. DATED this ____ day of ___________________, 20____. ______________________________________ (Signature) ______________________________________ (Print Name) Date of signing: __________________ Place of signing: __________________ RCW 11.88 Written Statement of Background and Qualifications Page 3 Revised 1/31/05 American LegalNet, Inc. www.USCourtForms.com