Superior Court of Washington County of __________________ In re the Guardianship of: No. ___________________ Petition for Washington to Accept a Guardianship or Conservatorship from a Transferring State (RCW 11.90.410) (PT) ______________________________, Incapacitated Person. I am the guardian or conservator of an incapacitated person in another state. I am petitioning the Washington Court to enter a provisional order accepting the transfer of a guardianship or conservatorship from that other state under RCW 11.90.410. 1. Information about the Petitioner (the guardian or conservator in another state) Name: ______________________________ Relationship to Incapacitated Person: ______________________________ (Instead of filling out the information on this form, you can complete and file a Confidential Information Form:) Street Address: Mailing Address: ______________________________ ______________________________ ______________________________ ______________________________ Contact Phone Number/s: ______________________________ 2. Information about the Incapacitated Person Name: Age: ______________________________ ______________________________ Petition for Washington to Accept a Guardianship (PT) Page 1 of 5 or Conservatorship from a Transferring State WPF GDN 02.0130 (07/2015) RCW 11.90.410 American LegalNet, Inc. www.FormsWorkFlow.com (Instead of filling out the information on this form, you can complete and file a Confidential Information Form:) Street Address: Mailing Address: ______________________________ ______________________________ ______________________________ ______________________________ Contact Phone Number/s: ______________________________ 3. Information about the Case in the Transferring State A. A guardianship or conservatorship is currently in: ________________________ (name of state). This state is called the "transferring state." B. Name of the court the case is filed in: __________________________________. (Example: Mason County District Court.) C. Case number: ______________________________________. D. The guardianship or conservatorship is a: Full Full Limited Guardian of the Person and/or Limited Guardian/conservator of the Estate 4. Basis to Accept the Transfer I have filed a certified copy of the transferring state's provisional order of transfer. A certified copy of the Order Appointing Guardian/Conservator signed by the transferring state is: included in or attached to the provisional order of transfer. filed separately or attached to this petition. I am eligible to be appointed as a guardian in Washington. I am over the age of eighteen, of sound mind, and I have not been convicted of a felony or misdemeanor involving moral turpitude, and I am otherwise suitable and eligible to be appointed guardian in the State of Washington. I do not reside in Washington State. I have appointed a resident agent and filed the Designation of and Consent by In-State (Resident) Agent form. There is other information I want the court to consider: . Petition for Washington to Accept a Guardianship (PT) Page 2 of 5 or Conservatorship from a Transferring State WPF GDN 02.0130 (07/2015) RCW 11.90.410 American LegalNet, Inc. www.FormsWorkFlow.com 5. People Entitled to Notice Name: Address: ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ ______________________________ Relationship to Incapacitated Person: ______________________________ Name: Address: Relationship to Incapacitated Person: ___________________________________ Name: Address: Relationship to Incapacitated Person: ______________________________ (Attach more sheets if you need to.) 6. Financial Information The approximate value and the description of the property owned by the alleged incapacitated person are: A. Assets: 1. Real Property: $________________________ (State/s where property is located _________________ _______________________) 2. Stocks, Mutual Funds, & Bonds: $________________________ 3. Mortgages and Notes: $________________________ 4. Bank Accounts: $________________________ 5. Other Property: $________________________ Description of other property: _____________________________ _____________________________ The total approximate value of assets is: $________________________ The alleged incapacitated person receives compensation, pension, insurance, and allowances as follows: B. Monthly Income: 1. Social Security Benefits: 2. Veterans' Benefits : 3. Washington State Assistance: 4. Retirement Income: 5. ______________________: 6. ______________________: 7. ______________________: The total approximate monthly income is: Petition for Washington to Accept a Guardianship (PT) Page 3 of 5 or Conservatorship from a Transferring State WPF GDN 02.0130 (07/2015) RCW 11.90.410 American LegalNet, Inc. www.FormsWorkFlow.com $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ $___________________ 7. Lay Guardian Training The proposed guardian in Washington has already completed lay guardian training. Evidence that he or she successfully completed the training is attached to the petition or filed separately. I request an extension of up to 90 days after provisional appointment for the guardian to complete and file proof of completion of the training because: . (If the court grants your request, evidence of successful completion of the lay guardian training will not be required until later.) The proposed Washington guardian is not required to complete lay guardian training because he or she is: a certified professional guardian, a financial institution subject to the jurisdiction of the department of financial institutions and authorized to exercise trust powers, or a federally chartered financial institution authorized to serve as a guardian of the estate. 8. Relief Requested: I am asking the court to enter: an order provisionally granting this Petition for Washington to Accept a Guardianship or Conservatorship from a Transferring State. an order directing the guardian or conservator to request the transferring state to issue a final order confirming the transfer to Washington, and terminating the guardianship or conservatorship in the transferring state. an order directing the court clerk to issue provisional Letters of