(Clerk’s Date Stamp) (Copy Receipt) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In the Guardianship of: CASE NO.: _____________________ _______________________________ An Incapacitated Person PETITION FOR APPROVAL OF BUDGET, DISBURSEMENTS, AND INITIAL PERSONAL CARE PLAN (PT) 1. Appointment of Guardian. _____________________________ (name) was appointed Guardian of the Person and/or Estate of the Incapacitated Person and immediately thereafter qualified by filing an oath and obtaining bond in the amount ordered by this Court. Letters of Guardianship were issued on ____________________(date). 2. Inventory. An inventory of the assets of the Incapacitated Person as of the date of appointment is filed separately. 3. Initial Personal Care Plan. The Incapacitated Person resides at ____________________ _______________________________________ (name of facility and address). An Initial Personal Care Plan describing the Incapacitated Person’s condition, living circumstances and the actions of the Guardian taken to benefit the Incapacitated Person is filed separately. The Guardian asks that the Court review and approve this Initial Personal Care Plan. #33A-GUARDIAN’S PETITION FOR APPROVAL OF BUDGET, DISBURSEMENT, AND INITIAL PERSONAL CARE PLAN PAGE 1 OF 3 Revised 3/07 American LegalNet, Inc. www.FormsWorkflow.com 4. Income and Current Expenses. The Incapacitated Person’s only income is as follows: Interests/Dividends Social Security Pension (Including Veteran’s or Otherwise) Other $ $ $ $ Total Monthly Income $ The Guardian should have authority to receive the Incapacitated Person’s income to be applied against the Incapacitated Person’s estimated expenses. The Guardian requests approval of the following budget for the twelve-month period following the appointment (fill in only those that apply): Room and Board Medical Rent/Mortgage Personal and Incidental Expenses Food and Household Expenses Utilities Guardian Fees Attorney Fees and Costs Other Total Proposed Monthly Expenditures $ $ $ $ $ $ $ $ $ $ 5.. Medical and Dental Expenses. The Guardian should be permitted to incur and pay any reasonable and necessary medical and dental expenses, which the Guardian determines to be in the best interest of the Incapacitated Person. 6.. Income Tax Payment/Accounting Fees. The Guardian may be required to file federal income tax returns and pay income tax due on Guardianship income. The Guardian should be permitted to pay fees for accounting services required in connection with the preparation of income tax returns. #33A-GUARDIAN’S PETITION FOR APPROVAL OF BUDGET, DISBURSEMENT, AND INITIAL PERSONAL CARE PLAN PAGE 2 OF 3 Revised 3/07 American LegalNet, Inc. www.FormsWorkflow.com 7.. Requests of Court. The Guardian requests that the Court enter an Order as follows: a. Approval of Budget. Approving this proposed budget of the Guardian. b. Income and Expenses. Authorizing the Guardian to continue receiving the Incapacitated Person’s income to be applied against the expenses set forth above. c. Reasonable Medical and Dental Expenses. Authorizing payment by the Guardian of any reasonable and necessary medical and dental expenses which the Guardian determines to be in the best interest of the Incapacitated Person. d. Initial Personal Care Plan and Inventory. Approving the Initial Personal Care Plan and Inventory separately submitted by the Guardian. e. Miscellaneous Expenses. Authorizing payment by the Guardian of miscellaneous expenses in an amount not to exceed $50.00 per month without further order of the Court for court fees and other miscellaneous expenses which the Guardian may incur during the course of the administration of this Guardianship; and f. Other Order. For any other Order that the Court deems appropriate. 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. SIGNED AT ______________, WASHINGTON THIS ____ DAY OF______________, 20___. Signature of Guardian/Attorney Printed Name of Guardian/Attorney, WSBA/CPG# Address City, State, Zip Code *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. #33A-GUARDIAN’S PETITION FOR APPROVAL OF BUDGET, DISBURSEMENT, AND INITIAL PERSONAL CARE PLAN PAGE 3 OF 3 Revised 3/07 American LegalNet, Inc. www.FormsWorkflow.com