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FORM M 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: Mailing Address of Proposed Guardian: Street Address (if different): City/State/Zip: Telephone Number: Fax Number: Email Address: If the proposed Guardian does not reside in Washington, provide the name, address, phone and email for the proposed Guardian's resident agent: Non-Professional Status. I am not charging fees for carrying out the duties of court-appointed guardian of three or more incapacitated persons. I acknowledge that before I may receive fees for serving as a Guardian for three or more persons, I am required to be certified in the State of Washington. See RCW § 11.88.008. Business Form. If appointed, I will serve as a Guardian as an individual and not as an entity or representative of a business entity, such as a trust company or non-profit corporation. Background and Experience Helpful to Service as Guardian. I have the following background, education training and experience, which may be helpful in my service as Guardian: Licenses held: Relationship to Alleged Incapacitated Person. I have the following relationship to the Alleged Incapacitated Person (such as family member, friend, etc.): Prior History as Fiduciary or Guardian. (a) I have served in a fiduciary capacity (such as an attorney-in-fact pursuant to power of attorney, a trustee, an executor, an administrator, or a Guardian). Yes No (b) I have been removed as a fiduciary. Yes No If the answer above is "Yes," describe the circumstances leading to your removal as a Guardian or as a fiduciary. Criminal History. RCW 11.88.020(3) expressly provides that no person is qualified to serve as a Guardian if he or she has been "convicted of a felony or of a misdemeanor involving moral turpitude," 88 American LegalNet, Inc. www.FormsWorkFlow.com CAUSE NO. DECLARATION OF PROPOSED GUARDIAN (Non-Certified) (2) (3) (4) (5) (6) (7) (8) (a crime involving dishonesty, misappropriation of funds, breach of fiduciary duty, or mistreatment of any person). I have been convicted of such a crime Yes No If the answer to the question is "Yes," identify all such convictions dated, and whether or not your civil rights have been restored. (9) Civil Proceedings. Describe any civil or administrative proceeding in which there was a finding that you had engaged in dishonesty, misappropriation of funds, breach of fiduciary duty, or mistreatment of any person. Also identify any proceeding(s) where there was a settlement, even if such settlement was without specific findings by the Court. (10) Disciplinary Proceedings. Describe any disciplinary proceeding against you by any applicable disciplinary body or licensing agency that resulted in a finding of misconduct. This would include any proceedings by a professional organization such as a state bar association, a medical disciplinary review board and the like: (11) Ability to Secure Bond. In some cases, it is necessary for the Guardian to secure a bond, which is insurance coverage providing protection to the Incapacitated Person in the event of financial loss or personal harm caused by the negligent or intentional conduct of the proposed Guardian. Is there any reason (such as bankruptcy or poor credit record) why you would have difficulty obtaining a Guardian's bond. If yes, please explain: (12) Compensation and Reimbursement. State whether you intend to request hourly compensation for your services and describe the expenses (e.g. mileage, postage copies charges, etc.) for which you expect to be reimbursed. (13) 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. 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 Person 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. 89 American LegalNet, Inc. www.FormsWorkFlow.com For health care decisions, "Before any person authorized to provide informed consent on behalf of a patient not competent to consent exercises that authority, the person must first determine in good faith that that patient, if competent, would consent to the proposed health care. If such a determination cannot be made, the decision to consent to the proposed health care may be made only after determining that the proposed health care is in the patient's best interests." RCW § 7.70.065(3) If my personal beliefs could be in conflict with the interests of the Alleged Incapacitated Person, I must first do what I believe the Incapacitated Person would do if competent. If that cannot be determined, either because of lack of knowledge or because the Incapacitated Person has always been disabled, I may act in the manner that I believe is in the best interest of the Alleged Incapacitated Person. I understand that at any time I can seek direction from the court if there is any question of what is in the best interest of the Alleged Incapacitated Person. 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. The attorney-client privilege may not extend to information given by me, the Guardian, to my attorney, for any failure to follow the laws of a court-appointed Guardian. If I am appointed the Guardian of the Person or Guardian of the Estate I must: file a Designation of Standby Guardian