(Copy Receipt) (Clerk’s Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF ___________________ In the Guardianship of: CASE NO. __________________________ _____________________________________ DECLARATION OF PROPOSED GUARDIAN (Certified) (DCLR) 1. Personal Information. Name of Proposed Guardian: ___________________________________________________ Certified Professional Guardian #: _______________________________________________ Mailing Address of Proposed Guardian: ___________________________________________ Street Address (if different): ____________________________________________________ City/State/Zip: _______________________________________________________________ Telephone Number: _________________________ Fax Number: _____________________ Email Address: ____________________________________________ 2. Certified Status. The proposed Guardian is a certified professional Guardian in the State of Washington. Attached as Exhibit A to this Declaration is a summary listing the educational programs (pertaining to Guardianships or fiduciary matters) which the proposed Guardian and its employees have attended during the past twelve (12) months. 3. Business Form. The form in which the proposed Guardian does business is: sole proprietor partnership trust company #08-DECLARATION OF PROPOSED GUARDIAN (CERTIFIED) PAGE 1 OF 4 American LegalNet, Inc. www.USCourtForms.com corporation non-profit corporation 4. Identification of Principals of Proposed Guardian. List the name of each member of the board of directors, officer, and owner of the business of the proposed Guardian and their title: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 5. Individual Certified Guardians. List each certified Guardian in the employ of the Guardian who may have responsibilities in this case and the individual certified Guardian who will have supervising responsibility in this case. ____________________________________________. 6. Relationship to Allegedly Incapacitated Person. The proposed Guardian has the following relationship with the Incapacitated Person _________________________________________. 7. Guardian’s Organizational Structure. (a) Date the proposed Guardian began doing business: ____________________________. (b) Allocation of job responsibilities: __________________________________________ ______________________________________________________________________. (Brochures or other printed materials may be attached as an Exhibit in response to this question.) 1. Criminal Background Checks. Does the proposed Guardian conduct criminal background checks pursuant to RCW 43.43.832 on all employees or volunteers who will or may have unsupervised access to the Incapacitated Person? Yes No 2. Criminal and Disciplinary History. Provide the following information for the 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: ____________________________________________________ _______________________________________________________________________. #08-DECLARATION OF PROPOSED GUARDIAN (CERTIFIED) PAGE 2 OF 4 American LegalNet, Inc. www.USCourtForms.com (b) Criminal proceedings for a felony or misdemeanor involving moral turpitude, which resulted in a finding or plea of guilty (attach an explanation as an exhibit explaining why this individual is employed by the proposed Guardian): __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________. (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): ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________. (d) Reported disciplinary proceedings by a disciplinary body or licensing agency that resulted in a finding of misconduct (including proceedings by a professional organization such as a state bar association, a medical disciplinary review board, etc.): ___________________ ___________________________________________________________________________ ___________________________________________________________________________. 1. Bond/Insurance. The nature and extent of the proposed Guardian’s insurance coverage 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: ___________________________________________________________________________ ___________________________________________________________________________. 2. Compensation and Reimbursement. The proposed Guardian’s compensation schedule is as follows (include the different hourly rates for various services): ______________________ ____________________________________________________________________________ _____________________________________________________________________________. #08-DECLARATION OF PROPOSED GUARDIAN (CERTIFIED) PAGE 3 OF 4 American LegalNet, Inc. www.USCourtForms.com 3. Experience. The proposed Guardian’s experience with similar Guardianships (for example, similar amount of assets, the family circumstances of the Incapacitated Person, the proximity of the proposed Guardian to the residence of the Alleged Incapacitated Person, and any relevant information) is: ______________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________. 4. Case Load. The Guardian is currently the Court appointed Guardian for _______ of total individuals in this County and _______ individuals in other Counties. I certify (or declare) under penalty of perjury under the laws of the State of Washington that to the best of my knowledge the statements above are true and correct. Signature of Certified Professional Guardian Printed Name of Certified Professional Guardian, WSBA/CPG# Address Telephone/Fax Number City, State, Zip Code Email Address #08-DECLARATION OF PROPOSED GUARDIAN (CERTIFIED) PAGE 4 OF 4 American LegalNet, Inc. www.USCourtForms.com