(Copy Receipt) (Clerk’s Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In the Guardianship of: An Incapacitated Person CASE NO. ORDER APPOINTING LIMITED FULL GUARDIAN OF PERSON AND/OR LIMITED FULL GUARDIAN OF ESTATE (ORAPGD) (CLERK’S ACTION REQUIRED) CLERK’S INFORMATION SUMMARY Due Date for Initial Personal Care Plan and Inventory: Due Date for Receipt(s) of Funds in Blocked Account(s): Due Date for Report and Accounting: Due Date for Filing Fee: The Clerk Shall Notify the Auditor of Loss of Voting Rights Yes No Certified Professional Guardian Non Professional Guardian (training required) THIS MATTER came on regularly for hearing on a Petition for Appointment of Guardian or Limited Guardian of , the Alleged Incapacitated Person. The Alleged Incapacitated Person was present in Court; The hearing was conducted outside of the courtroom at the location of the Alleged Incapacitated Person; #10-ORDER APPOINTING GUARDIAN OF PERSON AND/OR ESTATE PAGE 1 OF 8 Revised 3/08 American LegalNet, Inc. www.FormsWorkflow.com The Alleged Incapacitated Person’s presence was waived for good cause shown other than mere inconvenience, as set forth in the file and reports in this matter; The Guardian ad Litem was present. The following other persons were also present at the hearing: The Court considered the written report of the Guardian ad Litem and the Medical/ Psychological/ARNP Report, the testimony of witnesses, remarks of counsel, and the documents filed herein. Based on the above, the Court makes the following: I. FINDINGS OF FACT 1. Notices: All notices required by law have been given and proof of service as required by statute is on file. Notice, if required, was provided to the Regional Administrator of DSHS pursuant to RCW 11.92.150, but DSHS neither appeared at this hearing nor responded to the Petition. 2. Jurisdiction: The jurisdictional facts set forth in the petition are true and correct, and the Court has jurisdiction over the person and/or estate of the Alleged Incapacitated Person. 3. Guardian ad Litem: The Guardian ad Litem appointed by the Court has filed a report with the Court. The report is complete and complies with all requirements of RCW 11.88.090. 4. Alternative Arrangements Made By The Alleged Incapacitated Person: The Alleged Incapacitated Person did not make alternative arrangements for assistance, such as a power of attorney, prior to becoming incapacitated. The Alleged Incapacitated Person made alternative arrangements for assistance, but such arrangements are inadequate in the following respects: __________________________________ has been acting in a fiduciary capacity for the Alleged Incapacitated Person and should NOT continue to do so for the following reasons: 5. Capacity: The Alleged Incapacitated Person, , is incapable of managing their personal affairs incapable of managing their financial affairs #10-ORDER APPOINTING GUARDIAN OF PERSON AND/OR ESTATE PAGE 2 OF 8 Revised 3/08 American LegalNet, Inc. www.FormsWorkflow.com the Alleged Incapacitated Person is in need of a full Guardianship over the person estate the Alleged Incapacitated Person is capable of managing some personal and/or financial affairs, but is in need of the protection and assistance of a limited Guardian of the person estate, in the areas as follows: 6. Guardian: The proposed Guardian is qualified to act as Guardian of the Person and/or Estate of the Incapacitated Person. Proposed Guardian’s address, phone numbers and email address are as follows: Address: *Telephone #(s): Business Personal E-mail address: 7. Guardian ad Litem Fees and Costs: The Guardian ad Litem was appointed at County estate expense and shall submit a motion for payment of fees and costs pursuant to the local rules. The Guardian ad Litem has requested a fee of $ of $ for costs incurred while acting as Guardian ad Litem. Fees in the amount of $ and costs in the amount of $ $ for services rendered and reimbursement are reasonable and should be paid as follows: by the Guardian from the guardianship estate and/or $ by for the following reason(s): 8. Bond: The assets of the Alleged Incapacitated Person: Total less than three thousand dollars ($3,000) and no bond is required. Exceed three thousand dollars ($3,000) and should be placed in a blocked account with an insured financial institution or bonded, unless the guardian is a bank or trust company. Are to be held by a nonprofit corporation authorized to act as Guardian, and the Court waives any bond requirement. 9. Right to Vote: The Alleged Incapacitated Person is is not capable of exercising the right to vote. II. #10-ORDER APPOINTING GUARDIAN OF PERSON AND/OR ESTATE PAGE 3 OF 8 Revised 3/08 American LegalNet, Inc. www.FormsWorkflow.com CONCLUSIONS OF LAW 1. That is an Incapacitated Person within the meaning of RCW Chapter 11.88, and a Full Limited Guardian of the Person and/or Full Limited Guardian of the Estate should be appointed; and that is a fit and proper person as required by RCW 11.88.020 to be appointed. 2. That the powers of the Guardian and the limitations and restrictions placed on the Incapacitated Person should be as follows: The right to vote is revoked. Other: III. ORDER It is hereby ordered: 1. Prior Power of Attorney: Any Power of Attorney of any kind previously executed by the Incapacitated Person: is not canceled is canceled in its entirety is canceled in its entirety except for those provisions pertaining to health care. 2. Appointment of Guardian: is appointed as Full Limited Guardian of the Person and/or Full Limited Guardian of the Estate of , and the powers of the Guardian and the limitation and restrictions placed on the Incapacitated Person shall be as set forth in Conclusion of Law 2. 3. Letters of Guardianship/Limited Guardianship: The Clerk of the Court shall issue letters of Full Full Limited Guardianship of the Person and/or Limited Guardianship of the Estate to , upon the filing of an oath, Verification of Completion of Mandatory Guardian Training or an order waiving training, Guardianship bond in the amount of $ or bond is waived. #10-ORDER APPOINTING GUARDIAN OF PERSON AND/OR ESTATE PAGE 4 OF 8 Revised 3/08 American LegalNet, Inc. www.FormsWorkflow.com The following account(s) shall be accessible to the Guardian and all other accounts shall be blocked and a receipt of Funds in Blocked Account (Form #37) shall be filed with the court no later than 30 days from the date of this order: If bond is waived, the Guardian is required to report to the Court if the total assets of the Incapacitated Person reaches or exceeds Three Thousand Dollars. Pursuant to RCW 11.88.100, the Guardian of the Estate shall file a yearly statement showing the monthly income of the Incapacitated Person if said monthly income, excluding moneys from state or federal benefits, is over the sum of Five Hundred Dollars per month for any three consecutive months. 4. Report of Substantial Change in Income or Assets: Within 30 days of any substantial change in the Estate’s income or assets, the Guardian of the Estate shall report to the Court and schedule a hearing. The purpose of the hearing will be for the Court to consider changing the bond or making other provision in accordance with RCW 11.88.100. 5. Inventory: Within three months of appointment, the Guardian of the Estate shall file a verified Inventory of all the property of the Incapacitated Person, which shall come into the Guardian’s possession or knowledge, including a statement of all encumbrances, liens and other secured charges on any item. A review hearing upon filing of the inventory is required is not required. 6. Disbursements: On or before the date the Inventory is due, the Guardian of the Estate shall also apply to the Court for an Order Authorizing Disbursements on behalf of the Incapacitated Person as required by RCW 11.92.040. 7. Personal Care Plan: The Guardian of the Person shall complete and file within three (3) months after appointment a Personal Care Plan which shall comply with the requirements of RCW 11.92.043(1). 8. Status of Incapacitated Person: Unless otherwise ordered, the Guardian of the Person shall file an annual report on the status of the Incapacitated Person that shall comply with the requirements of RCW 11.92.043(2). #10-ORDER APPOINTING GUARDIAN OF PERSON AND/OR ESTATE PAGE 5 OF 8 Revised 3/08 American LegalNet, Inc. www.FormsWorkflow.com 9. Substantial Change in Condition or Residence: The Guardian of the Person shall report to the Court within thirty (30) days any substantial change in the Incapacitated Person’s condition, or any change in residence of the Incapacitated Person. 10. Designation of Standby Guardian: The Guardian shall file a written designation of a standby Guardian that complies with the requirements of RCW 11.88.125. 11. Authority for Investment and Expenditure: The authority of the Guardian of the Estate for investment and expenditure of the ward’s estate is as follows: 12. Duration of Guardianship: This Guardianship shall continue in effect: until [date]; OR until terminated pursuant to RCW 11.88.140; the necessity for the Guardianship to continue shall be periodically reviewed. 13. Discharge/Retention of Guardian ad Litem: The Guardian ad Litem is discharged; or The Guardian ad Litem shall continue performing further duties or obligations as follows: 14. Notice of Right to Receive Pleadings: The following persons are described in RCW 11.88.090(5)(d), and the Guardian shall notify them of their right to file with the Court and serve upon the Guardian, or the Guardian’s attorney, a request to receive copies of pleadings filed by the Guardian with respect to the Guardianship: Name Address 15. Guardian Fees: DSHS cases: The Guardian is allowed such fees and costs as permitted by the Washington Administrative Code in the amount of $ per month as a deduction from the incapacitated person’s participation in the DSHS cost of care. Such fees are subject to court review and approval. This deduction is approved for the initial twelve month reporting period and ninety days thereafter, from the date of this order to . The Guardian may petition for fees in #10-ORDER APPOINTING GUARDIAN OF PERSON AND/OR ESTATE PAGE 6 OF 8 Revised 3/08 American LegalNet, Inc. www.FormsWorkflow.com excess of the above amount only on notice to the appropriate DSHS Regional Administrator per WAC 388.71; OR Non-DSHS cases: The Guardian shall petition the Court for approval of fees. The Guardian may advance itself $ per month subject to Court review and approval. 16. Guardian ad Litem Fee: Fees and costs are approved as reasonable; OR The Guardian ad Litem fees and costs are approved as reasonable in the total amount of $ . They shall be paid from Spokane County, OR the Guardianship estate assets, other source(s) as follows: 17. Legal Fees: The legal fees and costs of $ . are approved as reasonable in the amount of , and shall be paid from the Guardianship estate assets OR other source(s) as follows: 18. Guardian’s Report: The Guardian’s report shall cover the 12 (twelve) month 24 (twenty-four) month or 36 (thirty-six) month period following the appointment. The Guardian’s report is due within 90 days of the end of the reporting period and shall comply with the requirements of RCW 11.92.040(2). DATED AND SIGNED IN OPEN COURT THIS DAY OF , 20 ________________________________________________ Judge/Court Commissioner Presented by: Signature of Petitioner/Attorney Printed Name of Petitioner/Attorney, WSBA/CPG # Address City, State, Zip Code #10-ORDER APPOINTING GUARDIAN OF PERSON AND/OR ESTATE PAGE 7 OF 8 Revised 3/08 American LegalNet, Inc. www.FormsWorkflow.com *Telephone/Fax Number Email Address *Under GR 22 (b) (6), parties’ personal telephone number(s) are confidential information. If you do not want your personal phone number(s) on this public form, complete form #S2-Sealed Confidential Information and file in the confidential file. Copy received and approved by: __________________________________ Guardian Ad Litem #10-ORDER APPOINTING GUARDIAN OF PERSON AND/OR ESTATE PAGE 8 OF 8 Revised 3/08 American LegalNet, Inc. www.FormsWorkflow.com