(Copy Receipt) (Clerk's Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE CASE NO. _______________ In the Guardianship of: GUARDIAN AD LITEM'S STATEMENT OF QUALIFICATIONS RCW 11.88.090(3) (ST) ______________________ GUARDIAN AD LITEM STATEMENT OF QUALIFICATIONS This statement is presented as required by RCW 11.88.090(3): A. Requisite areas of background, knowledge, training, and experience are detailed below: 1. Level of formal education: ____________________ 2. Training related to Guardian ad Litem duties: ____________________________ 3. Number of years' experience as Guardian ad Litem: ________________ 4. Number of prior appointments as Guardian ad Litem (as of today's date): (a) This County: ____________ (b) Other Counties: ___________ 5. Hourly Rate charged $_____________ 6. Criminal history (as defined in RCW 9.94.A.030, must include prior ten years): 7. Knowledge or experience in needs of: (a) Impaired elderly: ______________ GUARDIAN AD LITEM'S STATEMENT OF QUALIFICATIONS (ST) - PAGE 1 OF 3 SPO GDN 02.0400 (12/2014) American LegalNet, Inc. www.FormsWorkFlow.com (b) Persons with physical disabilities: _________________ (c) Persons with mental illness: _____________ (d) Persons with developmental disabilities: ____________ (e) Other incapacitated persons: ____________ 8. Familiarity and experience with legal procedures involving Guardianships: __________ 9. Familiarity and experience in dealing with the provisions of Chapter(s) 11.88 and 11.92 RCW: _____________________________ B. I have been removed as a Guardian ad Litem: 1. Yes No 2. If yes, please explain each instance on a page attached hereto. C. I have successfully completed the model Guardian ad Litem training program of this County on [month/day], _____ [year] at . D. I have had contact with a party in this proceeding prior to appointment: 1. Yes No 2. If yes, please explain each instance on a page attached hereto. E. I have had an apparent conflict of interest involving a party in this case: 1. Yes No 2. If yes, please explain each instance on a page attached hereto. 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 Petitioner Printed Name of Petitioner GUARDIAN AD LITEM'S STATEMENT OF QUALIFICATIONS (ST) - PAGE 2 OF 3 SPO GDN 02.0400 (12/2014) American LegalNet, Inc. www.FormsWorkFlow.com Address Telephone/Fax Number City, State, Zip Code Email Address GUARDIAN AD LITEM'S STATEMENT OF QUALIFICATIONS (ST) - PAGE 3 OF 3 SPO GDN 02.0400 (12/2014) American LegalNet, Inc. www.FormsWorkFlow.com