Declaration Of Proposed Guardian Certified {08}

(Copy Receipt) (Clerk's Date Stamp) SUPERIOR COURT OF WASHINGTON COUNTY OF SPOKANE In the Guardianship of: ____________________________________ CASE NO. _________________________ DECLARATION OF PROPOSED GUARDIAN (Certified) (DCLR) 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: DECLARATION OF PROPOSED GUARDIAN (CERTIFIED (DCLR) SPO GDN 02.0800 PAGE 1 OF 4 REV: 10/10 American LegalNet, Inc. www.FormsWorkFlow.com sole proprietor corporation partnership non-profit corporation trust company 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 Allegedly Incapacitated Person. The proposed Guardian has the following relationship with the Incapacitated Person __________________________________________. 7. Guardian's Organizational Structure. (a) Date the proposed Guardian began doing business: _____________________________. (b) Allocation of job responsibilities: ___________________________________________. (Brochures or other printed materials may be attached as an Exhibit in response to this question.) 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 the Incapacitated Person? Yes No 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: (a) Circumstances leading to removal as a Guardian or as a fiduciary for breach of fiduciary duty or for any other reason: ________________________________________________ ___________________________________________________________________________. DECLARATION OF PROPOSED GUARDIAN (CERTIFIED (DCLR) SPO GDN 02.0800 PAGE 2 OF 4 REV: 10/10 American LegalNet, Inc. www.FormsWorkFlow.com (b) 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): __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________. (c) 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): _________________________________________________________________________ _________________________________________________________________________ _________________________________________________________________________. (d) Reported disciplinary proceedings and/or any pending grievances 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, certified professional guardian board, etc.): _______________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________. 10. Bond/Insurance. The nature and extent of the proposed Guardian's insurance coverage available to provide protection in the event of financial loss or personal harm caused by the negligent or intentional conduct of the proposed Guardian, its employees or agents (list the companies with which insurance or bond is obtained, the policy limit and deductibles) is: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________. 11. Compensation and Reimbursement. The proposed Guardian's compensation schedule is as follows (include the different hourly rates for various services): __________________ ________________________________________________________________________. DECLARATION OF PROPOSED GUARDIAN (CERTIFIED (DCLR) SPO GDN 02.0800 PAGE 3 OF 4 REV: 10/10 American LegalNet, Inc. www.FormsWorkFlow.com 12. 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: __________________________