(Clerk’s Date Stamp) (Copy Receipt) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In the Guardianship of: Case No.: _______________________ ____________________________________ DECLARATION OF PROPOSED GUARDIAN (Non-Certified) (DCLR) 1. Personal Information. Name of Proposed Guardian: ___________________________________________ List all other names by which the Proposed Guardian has been known and dates: _____________________________________ Mailing Address of Proposed Guardian: __________________________________ Street Address (if different): _______________________________________________ City/State/Zip: __________________________________________________________ Telephone Number: _________________________ Fax Number: ________________ Email Address: ____________________________________________ #09-DECLARATION OF PROPOSED GUARDIAN (NON-CERTIFIED) PAGE 1 OF 5 MODIFIED: 02/06 American LegalNet, Inc. www.USCourtForms.com If proposed Guardian does not reside in Washington, provide name, address, phone and email for resident agent: _______________________________________________________. 2. Non-Professional Status. I am NOT serving as a Guardian for pay for three or more persons. I acknowledge that before I may serve as a Guardian for three or more persons for pay, I am required to be certified by the Washington Certified Professional Guardian Board. 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 non-profit 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: _______________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Professional licenses held and dates: ______________________________________________ ____________________________________________________________________________ _____________________________________________________________________________ 5. Relationship to Allegedly Incapacitated Person. I have the following relationship to the 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 No If yes, please list the county, state, name of the person(s) and date of each appointment: _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ #09-DECLARATION OF PROPOSED GUARDIAN (NON-CERTIFIED) PAGE 2 OF 5 MODIFIED: 02/06 American LegalNet, Inc. www.USCourtForms.com (b) I have been removed as a fiduciary. Yes No If the answer to 6(b) is “Yes,” describe the county, state, case number and 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, or any felony Yes No If the answer to the question is “Yes,” identify all such convictions, county and state, and date(s): _______________________________________________________________________ _____________________________________________________________________________. 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 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, nursing board and the like: ________________ ______________________________________________________________________________ ______________________________________________________________________________ #09-DECLARATION OF PROPOSED GUARDIAN (NON-CERTIFIED) PAGE 3 OF 5 MODIFIED: 02/06 American LegalNet, Inc. www.USCourtForms.com 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 Incapacitated Person in the event of financial loss or personal harm caused by the negligent or intentional conduct of the appointed Guardian. Is there any reason (such as bankruptcy or poor credit record) why you may have difficulty obtaining a Guardian’s bond. If yes, please explain: ________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 11. Compensation and Reimbursement. State whether you intend to request hourly or other compensation for your services, the basis for compensation, and describe the expenses for which you expect to be reimbursed. ____________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 12. Describe what you or others have done to help prepare you to be the guardian of the estate/person of: ___________________________________________ Check all that apply a. Reviewed RCW 11.88 with __________________________________ (Name) b. Reviewed RCW 11.92 with __________________________________ (Name) c. Reviewed the Spokane County Superior Court Guardians Manual with ___________________________________________________ (Name). d. Reviewed Spokane County Local Rule LSPR 98.20, Estates-Guardianships, with ________________________________________ (Name) e. Other Preparations: ________________________________________________ ________________________________________________________________________ #09-DECLARATION OF PROPOSED GUARDIAN (NON-CERTIFIED) PAGE 4 OF 5 MODIFIED: 02/06 American LegalNet, Inc. www.USCourtForms.com 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 Proposed Guardian Printed Name of Proposed Guardian, WSBA Address Telephone/Fax Number City, State, Zip Code Email Address RELEASE OF INFORMATION By my signature below, I authorize the Spokane County Superior Court to have or access the following information: 1) My date of birth 2) To confirm any information provided by me in the Declaration of Proposed Guardian through the Judicial Information System or Judicial Access Browser System. This would include any licensing authorities listed in said declaration regarding your licensing history. Date: ____________________ __________________________________ Proposed Guardian #09-DECLARATION OF PROPOSED GUARDIAN (NON-CERTIFIED) PAGE 5 OF 5 MODIFIED: 02/06 American LegalNet, Inc. www.USCourtForms.com