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IN THE SUPERIOR COURT OF THE STATE OF WASHINGTON FOR PIERCE COUNTY In Re the Guardianship of: [Name] An Incapacitated Person. Date Guardian Appointed: Date of Next Hearing: Current Bond Amount: Blocking Required: Due Date for Inventory: Due Date for Care Plan: Loss of Voting Rights Incapacitated Person (IP) Name: Address: Phone: Standby Guardian CAUSE NO. GUARDIANSHIP SUMMARY $ Yes No Yes No Guardian of: Name: Address: Phone: Facsimile: Address & Phone: Relation to IP Estate Person Interested Parties Address & Phone: Relation to IP I declare under the penalty of perjury that the above information is true and correct. I agree that if any of the above information changes, I will notify the court of that change within ten days of the change. Dated this_______ day of __________________, ________ at ____________________________ (day) (month) (year) (City & State) Signature Print Effective 9/1/06 American LegalNet, Inc. www.FormsWorkFlow.com