(Copy Receipt) (Clerk’s Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In the Guardianship of: CASE NO. __________________________ ___________________________________ An Alleged Incapacitated Person GUARDIAN AD LITEM REPORT RCW 11.88.090 (RTGAL) RECOMMENDATION: _______________________________________________________ 1. Procedural History. Date of Appointment: ____________________________________ Date of Service of Copy of Petition on Guardian ad Litem: ______________________________ Date Guardian ad Litem’s Statement of Qualifications was filed & served: __________________ I attest that I am on the Guardian ad Litem Registry for this County, have conducted approximately ________ Title XI Guardian ad Litem investigations, and am qualified to serve as Guardian ad Litem in Guardianship matters. 2. Medical/Psychological Report. As required by RCW 11.88.045, I have obtained a written, medical/psychological report from ________________________________. The report was filed with the Court on _______________________. (Do not attach medical report to GAL report.) The examining physician/psychologist/advanced registered nurse practitioner was selected by _______________________________. The reason for selecting this individual to prepare the medical/psychological report was _________________________________________________ ____________________________________________________________________________ #07-GUARDIAN AD LITEM REPORT PAGE 1 OF 6 MODIFIED: 3/07 American LegalNet, Inc. www.FormsWorkflow.com 3. Meeting(s) with Alleged Incapacitated Person. Dates of Meetings with Alleged Incapacitated Person Location of Meeting Other Persons Present (GAL must meet alone at least once with Alleged Incapacitated Person.) A. Personal Information Regarding Alleged Incapacitated Person: Date of Birth: Age: Current Residence: Telephone Numbers: DSHS Client Number: B. Incapacitated Person’s Responses Regarding Specific Issues: Agreement or objection to appointment of a Guardian: Reaction to the proposed Guardian: Right to counsel: Preferences regarding choice of counsel: Right to a jury trial: C. Summary of Interviews with Alleged Incapacitated Person and Guardian ad Litem’s Impressions. (Report as closely as possible the Alleged Incapacitated Person’s own words when appropriate.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 4. Investigation. A. Individuals Contacted. (Name each person contacted and date(s) of contact. Explain the relationship of the interviewed person with the case or Alleged Incapacitated Person and what information that person contributed to your understanding the circumstances surroundings the Guardianship Petition.) #07-GUARDIAN AD LITEM REPORT PAGE 2 OF 6 MODIFIED: 3/07 American LegalNet, Inc. www.FormsWorkflow.com ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ B. Written Materials Reviewed. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 5. Nature, Cause and Degree of Incapacity – Functional Limitations. A. Medical Diagnosis and Cause. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ B. Degree of Incapacity. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 6. Alternatives to Guardianship. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 7. Abilities of Alleged Incapacitated Person and Degree of Assistance Required. _____________________________________________________________________________ _____________________________________________________________________________ #07-GUARDIAN AD LITEM REPORT PAGE 3 OF 6 MODIFIED: 3/07 American LegalNet, Inc. www.FormsWorkflow.com _____________________________________________________________________________ 8. Recommendation as to Appointment of Guardian. _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ 9. Recommendation Regarding Alleged Incapacitated Person’s Right to Vote: _____________________________________________________________________________ 10. Evaluation of Proposed Guardian: A. Dates of Contact Between Guardian ad Litem and Proposed Guardian and Written Materials Reviewed: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ B. Identity and Contact Information Regarding Proposed Guardian: Name: Mailing Address: Street Address (if different from above) Telephone Numbers: Fax Number: Email Address If Guardian is Certified, Provide Certification No.: Relationship, if any, between Proposed Guardian and Alleged Incapacitated Person: ______________________________________________________________________________ C. Description of Steps Proposed Guardian Has or Intends to Take to Meet the Alleged Incapacitated Person’s Needs. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 11. Recommendation Regarding Advice of Right to Jury Trial. #07-GUARDIAN AD LITEM REPORT PAGE 4 OF 6 MODIFIED: 3/07 American LegalNet, Inc. www.FormsWorkflow.com ______________________________________________________________________________ 12. Recommendation Regarding Appointment of Independent Counsel. ______________________________________________________________________________ 13. Estimate of Estate (Based on Available Information). Real Property Cash on Hand Business Securities Mortgages and Notes Bank/Trust Account Cash Surrender Value Insurance Personal Property Sources of Income Other: $ $ $ $ $ $ $ $ $ $ $ $ $ ESTIMATED TOTAL $ 14. Recommendation Regarding Bond/Annual Reports. I recommend that: The Court set bond in the amount of $_______________________. The Court block or restrict access to the following assets: $____________________ The Guardian file financial reports every year every other year every third year 15. Recommendation Regarding Presence of Alleged Incapacitated Person at Hearing. The presence of the Alleged Incapacitated Person should should not be waived. _____________________________ is able unable to attend the hearing. If unable to attend, please explain the reason(s): _____________________ ______________________________________________________________________________ #07-GUARDIAN AD LITEM REPORT PAGE 5 OF 6 MODIFIED: 3/07 American LegalNet, Inc. www.FormsWorkflow.com The following special arrangements should be made for the hearing (i.e., relocation of hearing site to residence of Alleged Incapacitated Person, provision for hearing assistive devices, etc.). ______________________________________________________________________________ ______________________________________________________________________________ 16. Other Recommendations. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 17. Recommendation as to Guardian ad Litem’s Continuing Involvement in Future Proceedings. I recommend that the Guardian ad Litem be not be involved in future proceedings in this matter. 18. Individuals Who Should be Advised of Their Right to Request Special Notice of Proceedings Pursuant to RCW 11.92.150. Name, Title and Address Relationship to Alleged Incapacitated Person Dated this ________ day of ________________________, 20_______. 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 Guardian ad Litem Printed Name of Guardian ad Litem WSBA/CPG# Address City, State, Zip Code Telephone/Fax Number Email Address #07-GUARDIAN AD LITEM REPORT PAGE 6 OF 6 MODIFIED: 3/07 American LegalNet, Inc. www.FormsWorkflow.com