COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Plaintiff(s) -against- Calendar No. : JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... SUPERIOR COURT OF WASHINGTON IN AND FOR SNOHOMISH COUNTY THE PEOPLE OF THE STATE OF NEW YORK TO CASE NO. In the Guardianship of: PERSONAL CARE PLAN REPORT ON STATUS OF PERSON WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before GR , the Honorable at the 2 7-03 Court located at County of an Incapacitated Person. 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 GREETINGS: I. ASSESSMENT Your (Check one) 1. Housing: failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Lives alone result of your failure to Lives with spouse comply. Court in Lives with children Lives Witness, Honorablewith relative Other County, , one of the Justices of the day of , 20 2. Living Arrangement: (Check one) Home Owner Renter Adult Family Home Congregate Care Facility Nursing Home Senior Housing (Attorney must sign above and type name below) Attorney(s) for Other 3. Functional Limitation: Speech Hearing Vision Walking S:\Web Forms\ Superior Court\pdf\GrdnPersCarePlan.doc Office and P.O. Address RRU: 07/01/2003 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 1 of 10 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : 4. Prosthetic Devices: None Walker/Cane Wheelchair -againstHearing Aid Artificial Limb Dentures Plaintiff(s) Calendar No. : JUDICIAL SUBPOENA : : : 5. Needs Assistance to Leave Home: (Check one) Yes Defendant(s) : . . . . . . . . . . . . . . . . . . . No. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 6. Primary transportation: (Check one) Own car THE PEOPLE OF THEPublic Trans. NEW YORK STATE OF Friend/Relative TO Other 7. If Lives in Home-Services Need: None Chore Services GREETINGS: Other WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the8. Needs assistance for: Honorable at the Court Eating located at County of Toileting in room , on the day , 20 , at o'clock in the noon, and at any recessed Ambulation of or adjourned date, to testify and give evidence as a witness in this action on the part of the Transfer Positioning Personal Hygiene Dressing Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Bathing the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Medication result of your failure to Travel to Medical Services comply. Shopping with incapacitated person “ without incapacitated person Witness, Honorable , one of the Justices of the Meal Preparation Court in County, Facilities: day of , 20 Laundry in home not in home Housework (Attorney must sign above and type name below) Comments: Attorney(s) for Office and P.O. Address S:\Web Forms\ Superior Court\pdf\GrdnPersCarePlan.doc RRU: 07/01/2003 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 2 of 10 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. : JUDICIAL SUBPOENA Check one of the following codes for each item listed below: 9. Wards Ability to Handle Emergencies: Plaintiff(s) -against- Knows what to do in the event of a fire: Yes No Cannot Determine : : : Knows what to do in case of medical emergency (Doctor, ambulance): Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . .Yes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. No Cannot Determine THE PEOPLE OF THEKnows what to do in case of break-in or robbery: STATE OF NEW YORK Yes No Cannot Determine TO GREETINGS: Knows how to call emergency (911): Yes No Cannot Determine WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , thel0. Ward knows how to seek help from others to keep: Honorable at the Court Supply of goods and services (Housekeeper, Lawyer, Community Services): located at County of Yes in room , on the No day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify Cannot Determine as a witness in this action on the part of the and give evidence 11. Ward's Financial Abilities: Able to collect benefit, retirement, social security, VA benefits: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Yes No the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Cannot Determine result of your failure to comply. Able to Witness, Honorable maintain checking accounts with balance greater than the Justices of the , one of $ Yes Court in County, day of , 20 No Cannot Determine Able to pay monthly bills for rent, utilities, etc.: (Attorney must sign above and type name below) Yes No Cannot Determine Attorney(s) for Willing and able to spend money for necessary goods and services (food, clothing, etc): Yes No Cannot Determine Office and P.O. Address S:\Web Forms\ Superior Court\pdf\GrdnPersCarePlan.doc RRU: 07/01/2003 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 3 of 10 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Able to seek help in money management: Plaintiff(s) Yes No -againstCannot Determine Able to manage funds: Yes No Cannot Determine Defendant(s) Calendar No. : JUDICIAL SUBPOENA : : : : ...................................................... List sources of income STATE OF NEW YORK THE PEOPLE OF THEand/or resources to pay for monthly costs and care/services: TO GREETINGS: 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 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 Estimated monthly costs: Amount Housing: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Food: the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your Utilities: comply. failure to Clothing/Laundry: Witness, Honorable Medical: Court in County, Recreational: , one of the Justices of the day of , 20 Insurance: Other: (Please list) (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address S:\Web Forms\ Superior Court\pdf\GrdnPersCarePlan.doc RRU: 07/01/2003 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 4 of 10 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. : JUDICIAL SUBPOENA 12.Ward's Psychological/Social/Cognitive Functioning: Plaintiff(s) DISORIENTATION: -against- : Able to relate to person, place, or time: Yes No Cannot Determine : : MEMORY IMPAIRMENT: Defendant(s) : . . . . . . . . . . . . . . . .Can’t .remember. events occurring within .the .hour: .... ....... .................. .. ... Yes No Cannot Determine THE PEOPLE OF THE STATE OFevents occurring within the day: Can’t remember NEW YORK Yes No Cannot Determine TO Can’t remember events occurring within the week Yes No Cannot Determine WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before GREETINGS: , the Honorable at the Court IMPAIRED JUDGMENT: located at County of Able to make appropriate decisions, solve problems and respond to major life changes: in room , on the day of , 20 , at o'clock in the noon, and at any recessed Yes or adjourned date, to testify and give evidence as a witness in this action on the part of the No Cannot Determine COMMUNICATIONS: Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf thisAble to understand what is a maximum penalty of $50 and all damages sustained as a subpoena was issued for being said: result of your failure to comply. Yes No Cannot Determine Witness, Honorable Able to express thoughts and needs: Court in County, day of , 20 , one of the Justices of the Yes No Cannot Determine (Attorney must sign above and type name below) WANDERING: Moves about aimlessly, or in pursuit of an unobtainable goal: Yes Attorney(s) for No Cannot Determine Office and P.O. Address S:\Web Forms\ Superior Court\pdf\GrdnPersCarePlan.doc RRU: 07/01/2003 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 5 of 10 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : : VERBALLY ABUSIVE BEHAVIOR: Plaintiff(s) Calendar No. JUDICIAL SUBPOENA Threatens/berates others, yells, uses foul language, etc.: -against: Yes No Cannot Determine : : DISRUPTIVE OR INAPPROPRIATE BEHAVIOR: Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . Makes .excessive. demands . . . attention, takes another's possessions. Disrobes . . . . . . . . . . . . . . . . . . for . . . . . . in front of others, inappropriate sexual behavior, etc.: Yes No Cannot YORK THE PEOPLE OF THE STATE OF NEW Determine TO ASSAULTIVE OR COMBATIVE BEHAVIOR: Throws objects, strikes or punches, makes dangerous maneuvers, etc.: Yes No Cannot Determine GREETINGS: 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 DANGER TO SELF:day of in room , on the , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and self-neglect or harm, suicidalin this actionattempts, etc.: the Indicated by give evidence as a witness thoughts or on the part of Yes No Cannot Determine Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 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. OTHER IMPAIRMENTS IN THOUGHTS, MOODS OR BEHAVIOR: Witness, Please describe: Honorable Court in County, day of , one of the Justices of the , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address S:\Web Forms\ Superior Court\pdf\GrdnPersCarePlan.doc RRU: 07/01/2003 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 6 of 10 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : Calendar No. : JUDICIAL SUBPOENA II CARE PLAN Plaintiff(s) 1. Residence Address: -against- : Address: : City, State, Zip: : Plan for chore services provided in home (if necessary): Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: 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 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 Plan for nursing services and other medical or personal care service provided in home, adult family Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to home , or congregate care facility (if necessary): 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. Witness, Honorable Court in County, , 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 S:\Web Forms\ Superior Court\pdf\GrdnPersCarePlan.doc RRU: 07/01/2003 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 7 of 10 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : : Index No. Calendar No. Plan for other services, including rehabilitative, educational,:social, and recreational services: JUDICIAL SUBPOENA Plaintiff(s) -against- : : : Defendant(s) : ...................................................... THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: 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 2. Treating Physician(s): in room names, etc. on attachment if space insufficient) , on the day of , 20 , at o'clock in the noon, and at any recessed (Add or adjourned date, to testify and give evidence as a witness in this action on the part of the Name: Address: Phone number: ( ) Phone number: ( ) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to Name: the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Address: result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 3. Current Medications: (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address S:\Web Forms\ Superior Court\pdf\GrdnPersCarePlan.doc RRU: 07/01/2003 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 8 of 10 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : 4. Other Professionals Assisting Incapacitated Person: (Add names, etc. on attachment if space insufficient) Plaintiff(s) -against- Name: ( : JUDICIAL SUBPOENA : Address: Phone number: Calendar No. : ) Name: : Address: Defendant(s) : ( ) Phone number: ...................................................... Name: Address: Phone number: ( ) THE PEOPLE OF THE STATE OF NEW YORK TO 5. Other Significant Persons: (Add names, etc. on attachment if space insufficient) Name: GREETINGS: Address: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before ( ) Phone number: , the Honorable at the Court Name: located at County of Address: in room , on the day of , 20 , at o'clock in the noon, and at any recessed ) orPhone number: to( testify and give evidence as a witness in this action on the part of the adjourned date, Name: Address: Phone number: ( ) Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to 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. 6. Plan for Financial Management: Witness, Honorable (i.e. Person(s) responsible to receive income and pay monthly bills) Court in County, day of , one of the Justices of the , 20 (Attorney must sign above and type name below) Attorney(s) for Office and P.O. Address S:\Web Forms\ Superior Court\pdf\GrdnPersCarePlan.doc RRU: 07/01/2003 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 9 of 10 American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : Index No. : 7. Present Address of IP: Plaintiff(s) Name of Facility: -against- Calendar No. : JUDICIAL SUBPOENA : (Group home, etc., if applicable) : Address: : City, State, Zip: ( Phone: ) Defendant(s) : . . . . .Contact. Person:. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..... ..... 8. Present Address of Guardian(s) THE PEOPLE OF THE STATE OF NEW YORK Name(s) of Guardian(s): TO Address: City, State, Zip: ( ( Phone: Fax: ) ) GREETINGS: Email: 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 in room , on the day of , 20 , at o'clock in the noon, and at any recessed I/We declare under penalty of perjury as defined as a laws of in state of Washington that the foregoing is true and or adjourned date, to testify and give evidenceby thewitness the this action on the part of the correct. Signed at Your failure to comply with this subpoena ,is Washington as a contempt of court and will make you liable to punishable 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. Dated (mm/dd/yyyy): Witness, Honorable Court in County, , one of the Justices of the day of , 20 GUARDIAN: (Signature) (Attorney must sign above and type name below) GUARDIAN: (Signature) Attorney(s) for Office and P.O. Address S:\Web Forms\ Superior Court\pdf\GrdnPersCarePlan.doc RRU: 07/01/2003 Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 10 of 10 American LegalNet, Inc. www.USCourtForms.com