PT/Appr. Budget/Disbrsmnt/Ini.Pers. Care Plan (PTAPR) - Page 1 of 3 WPF GDN 05.0100 (01/2009) RCW 11.92.040 Superior Court of Washington County of In the Guardianship of: , Incapacitated Person N o . Petition For Approval Of Budget, Disbursements And Initial Personal Care Plan (PTAPR) I. Basis 1.1 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) . 1.2 Inventory An inventory of the assets of the Incapacitated Person as of the date of appointment is filed separately. 1.3 Initial Personal Care Plan The Incapacitated Person resides at (name of facility, if applicable, and address) . An Initial Personal Care Plan describing the Incapacitated Person222s 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 this Initial Personal Care Plan. American LegalNet, Inc. www.FormsWorkFlow.com PT/Appr. Budget/Disbrsmnt/Ini.Pers. Care Plan (PTAPR) - Page 2 of 3 WPF GDN 05.0100 (01/2009) RCW 11.92.040 1.4 Income and Current Expenses The Incapacitated Person222s income is as follows: Interests/Dividends $ Social Security $ Pe nsion (Including Veteran222s or Otherwise) $ Other $ Total Monthly Income $ 1.5 Authority of Guardian to Receive Income and Pay Expenses The Guardian should have authority to receive the Incapacitated Person222s income to be applied against the Incapacitated Person222s expenses. 1.6 Proposed Budget 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 Incid ental Expenses $ Food and Household Expenses $ Utilities $ Guardian Fees $ Attorney Fees and Costs $ Other $ Total Proposed Monthly Expenditures $ 1.7 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. 1.8 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. American LegalNet, Inc. www.FormsWorkFlow.com PT/Appr. Budget/Disbrsmnt/Ini.Pers. Care Plan (PTAPR) - Page 3 of 3 WPF GDN 05.0100 (01/2009) RCW 11.92.040 II. Relief Requested The Guardian requests that the court enter an Order as follows: 2.1 [ ] Approval of Budget Approving this proposed budget of the Guardian. 2.2 [ ] Income and Expenses Authorizing the Guardian to continue receiving the Incapacitated Person222s income to be applied against the expenses set forth above. 2.3 [ ] 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. 2.4 [ ] Initial Personal Care Plan and Inventory Approving the Initial Personal Care Plan and Inventory separately submitted by the Guardian. 2.5 [ ] 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. 2.6 [ ] 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 the foregoing is true and correct. Signed at (city) , (state) on (date) . Signature of Guardian/Attorney Print Name of Guardian/Attorney [ ]WSBA [ ]CPG# Address City, State, Zip Code *Telephone/Fax Number Email Address *If you do not want your personal phone number on this public form, you may list your telephone number on a separate form which may be available to parties and the court, as well as its staff and volunteers, but will not be made available to the public. Use Form WPF GDN 03.0100, Guardianship Confidential Information form (Telephone Numbers), for this purpose. American LegalNet, Inc. www.FormsWorkFlow.com