Declaration Of Proposed Guardian Certified

FORM N IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON FOR PIERCE COUNTY In Re the Guardianship of: [Name] An Incapacitated Person. 1) Personal Information. Name of Proposed Guardian: Certified Professional Guardian #: Mailing Address of Proposed Guardian: Street Address (if different): City/State/Zip: Telephone Number: Fax Number: Email Address: 2) Certified Status. The proposed Guardian is a certified professional Guardian in the State of Washington. Attached as Exhibit A to this Declaration is a summary listing the educational programs (pertaining to Guardianships or fiduciary matters) which the proposed Guardian and its employees have attended during the past twelve (12) months. 3) Business Form. The form in which the proposed Guardian does business is: sole proprietor partnership trust company corporation non-profit corporation 4) Identification of Principals of Proposed Guardian. List the name of each member of the board of directors, officer, and owner of the business of the proposed Guardian and their title: 5) Individual Certified Guardians. List each certified Guardian in the employ of the Guardian who may have responsibilities in this case and the individual certified Guardian who will have supervising responsibility in this case. 6) Relationship to Alleged Incapacitated Person. relationship with the Incapacitated Person: 7) Guardian's Organizational Structure. (1) Date the proposed Guardian began doing business: The proposed Guardian has the following CAUSE NO. DECLARATION OF PROPOSED GUARDIAN (Certified) (2) Allocation of job responsibilities: (Brochures or other printed materials may be attached as an Exhibit in response to this question.) 92 American LegalNet, Inc. www.FormsWorkFlow.com 8) Criminal Background Checks. Does the proposed Guardian conduct criminal background checks pursuant to RCW 43.43.832 on all employees or volunteers who will or may have unsupervised access to Yes No the Incapacitated Person? 9) Criminal and Disciplinary History. Provide the following information for the proposed Guardian and for each of its principals and employees who are certified professional Guardians. However, do NOT include employees who are neither principals nor certified Guardians: (1) Circumstances leading to removal as a Guardian or as a fiduciary for breach of fiduciary duty or for any other reason: (2) Criminal proceedings for a felony or misdemeanor involving moral turpitude, which resulted in a finding or plea of guilty (attach an explanation as an exhibit explaining why this individual is employed by the proposed Guardian): (3) Civil proceedings in which there was a finding of dishonesty, misappropriation of funds, breach of fiduciary duty, or mistreatment of any person (identify any civil proceedings where there was a settlement, even if such settlement was without specific findings by the Court): (4) Reported disciplinary proceedings by a disciplinary body or licensing agency that resulted in a finding of misconduct (including proceedings by a professional organization such as a state bar association, a medical disciplinary review board, etc.): 10) Bond/Insurance. The proposed Guardian has insurance coverage or security from the following forms at the following policy limits as of 20 : a) Errors and Omissions Insurance: i) Insurance Company: ii) Policy Limits: i) Insurance Company: ii) Policy Limits: c) General Surety Bond: i) Bonding Company: ii) Amount: $ $ $ b) Employee Dishonesty Insurance: 11) Assets Under Management. The total value of all of the assets that proposed Guardian has under management as of , 20 is: $ 12) Compensation and Reimbursement. The proposed Guardian's compensation schedule is as follows (include the different hourly rates for various services): 13) Experience. The proposed Guardian's experience with similar Guardianships (for example, similar amount of assets, the family circumstances of the Incapacitated Person, the proximity of the proposed Guardian to the residence of the Alleged Incapacitated Person, and any relevant information) is: 93 American LegalNet, Inc. www.FormsWorkFlow.com ,20____ the proposed Guardian is the Court appointed Guardian for [insert 14) Case Load. As of text-number] of total individuals, and serves as a non-guardian fiduciary (e.g. Trustee, Attorney in Fact, Custodian) for ________ number of total individuals. 15) Summary of Guardian Duties: The below signed proposed Guardian understands and agrees that: My duties as Guardian are more fully described in: (1) the Court Order that appoints me, (2) the statutes of the State of Washington ­ (for example see the Revised Code of Washington (RCW) at Chapters 11.88 & 11.92 and specifically 11.92.042 and 11.92.043 RCW.) (3) the case law. I should consult with my attorney if I have any questions about my duties and responsibilities. I am presumed to understand my duties and responsibilities. I can be held personally responsible if I do not properly carry out my duties as Guardian. As Guardian, I act in a fiduciary capacity in my dealings on behalf of the Incapacitated Person. This means that as the Guardian, I am required to put the interests of the Incapacitated Person ahead of my personal interests in all transactions as well as any transaction in which my interests and the interests of the Incapacitated Party may be in conflict. Additionally, if I have been appointed Guardian of the Estate, I am charged with the responsibility of acting as a reasonably prudent person in dealing with the investment and conservation of the assets of the Incapacitated Person; and to avoid self dealing. Any attorney that I retain to assist me in this guardianship proceeding will have independent responsibilities and obligations to the Court. The attorney-client privilege may not extend to information regarding misfeasance or malfeasance of a fiduciary. If I am appointed the Guardian of the Person or Guardian of the Estate I must: file a Designation of Standby Guardian with the Court; keep the Court informed of any change in my name, address, or bonding status; and file a Change of Circumstance Report within thirty (30) days of any change of location, major or permanent changes in health or finances, or of the death of the Incapacitated Person. file a Final Accounting within ninety (90) days after the termination of a guardianship. 11.92.053 RCW, see also 11.88.140 RCW If I am appointed the Guardian of the Estate I must also: keep the Incapacitated Person's funds separate from my own,