Superior Court of Washington County of Spokane Case No.: ____________________ In the Guardianship of: DECLARATION OF PROPOSED (Non-Certified) GUARDIAN SUCCESSOR GUARDIAN (DCLR) ______________________________, Incapacitated Person 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: ____________________________________________________ DECLARATION OF PROPOSED GUARDIAN (NON ­CERTIFIED) SPO GDN 02.0900 PAGE 1 OF 5 REV: 10/10 American LegalNet, Inc. www.FormsWorkFlow.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:_____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ (b) I have been removed as a fiduciary. Yes No DECLARATION OF PROPOSED GUARDIAN (NON ­CERTIFIED) SPO GDN 02.0900 PAGE 2 OF 5 REV: 10/10 American LegalNet, Inc. www.FormsWorkFlow.com 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 and/or any pending grievances 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, certified professional guardian board, and the like: _____________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ DECLARATION OF PROPOSED GUARDIAN (NON ­CERTIFIED) SPO GDN 02.0900 PAGE 3 OF 5 REV: 10/10 American LegalNet, Inc. www.FormsWorkFlow.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 r